Current Status and Problems of Preoperative Assessment for Elderly Cancer Surgery Patients in Japan: A Nationwide Survey

Elderly cancer patients requiring surgical treatment are increasing, and the deterioration of quality of life and shortening of healthy life expectancy due to postoperative complications represent major problems. This study investigated the current status of medical treatment, including perioperative evaluations, for elderly cancer patients requiring surgical treatment at cancer treatment facilities nationwide. A total of 436 cancer care facilities around Japan were invited to participate in this web-based survey regarding management of cancer patients ≥ 65 years old who had undergone surgical treatment in 2018. A total of 919 department heads from 245 facilities agreed to participate. Although most respondents answered that performance status, preoperative examinations, and comorbidities were important when deciding on a treatment plan, age, Geriatric Assessment (GA), and guidelines were "not important" for >10% of all respondents. GA was familiar to 195 department heads (21%), and awareness of GA was signicantly lower among respondents from medical education institutions than the other types of hospitals (18.5% vs 26.3%; P = 0.006). This large survey revealed that the use of GA is not widespread, and its awareness in medical education institutions remains low. We believe that accumulating evidence of geriatric oncology surgery is an urgent issue in Japan.


Introduction
With the current hyper-aging society present in Japan, mean age at onset of cancer is over 60 years, and 85% of cancer deaths occur in people ³65 years old [ 1,2 ]. Cancer is already a chronic disease of the elderly, and its treatment and care require the establishment of systems applicable not only to the medical community, but also to society as a whole. Declines in physiological functions, complications, comorbidities, declines in cognitive functions, and socioeconomic limitations such as institutionalization and living alone need to be taken into account when considering treatments in the elderly. These characteristics are thought to impact therapeutic e cacy and adverse events, and personalized medicine after pre-treatment evaluations is thus desirable. In particular, the number of elderly cancer patients requiring surgical treatment is increasing, and deterioration of quality of life (QOL) and shortening of healthy life expectancy due to postoperative complications represent major problems, and the establishment of treatment guidelines for elderly cancer patients is urgently needed.
The most important issue in the treatment of elderly cancer patients is to perform pre-treatment evaluations, but no consensus has yet been reached regarding the optimal methods for such evaluations and little evidence is currently available. Comprehensive Geriatric Assessment (CGA) is a method for comprehensively assessing functional impairment in the elderly [ 3 ]. CGA is a concept that combines assessment and intervention, and in oncology is referred to as Geriatric Assessment (GA), in the sense that only a comprehensive assessment is performed to determine a treatment plan [ 4 ]. GA is capable of assessing the elderly individual objectively and comprehensively, but is not widely used in daily practice in Japan, especially in cancer treatment. Previously, we have shown that Japanese gynecologic oncology doctors have lower awareness of CGA [ 5 ]. For this background, we surveyed the actual status of treatment, including perioperative evaluation, for elderly cancer patients at cancer treatment facilities nationwide to clarify the current status and problems of surgical treatment in elderly cancer care in Japan, and to collect basic data to develop treatment guidelines for elderly cancer patients. This study was conducted as an activity of the "Research on the infrastructure for development of clinical guidelines for elderly cancer patients" group as part of the Research Project for the Promotion of Cancer Control of the Ministry of Health, Labour and Welfare Sciences.

Materials And Methods
This nationwide survey of cancer care facilities was conducted from May to August 2020. Targets of the survey were all 393 designated cancer hospitals by the Ministry of Health, Labor and Welfare (51 prefectural base hospitals for cancer care, 14 regional base hospitals for cancer care (advanced type), 325 regional cooperation base hospitals for cancer care, 1 base hospital for cancer care in a speci c area, and 2 National Cancer Centers), and 43 regional base hospitals for cancer care. The following data were collected at a total of 436 facilities (as of April 1, 2019), including 43 regional cancer hospitals, for departments categorized into 12 types (neurosurgery, respiratory surgery, cardiac surgery, gastrointestinal surgery, hepatobiliary surgery, breast surgery, urology, gynecology, orthopedics, otorhinolaryngology/oral oncology, dermatology/plastic surgery, and others) during the year from the beginning of January to the end of December 2018. The survey investigated the management of patients with cancer ³65 years old who underwent surgical treatment during the same period. The survey was sent by mail and e-mail to hospital directors of the target facilities, requesting cooperation in the questionnaire, and asking the head of each department to respond via the web.

Survey items
Background characteristics of respondents Data requested included: years of experience as a physician; whether the respondent had obtained a medical specialty; whether the respondent had obtained a Ph.D. degree; the types of institution to which the respondent belonged; the specialty of the respondent, and the percentage of elderly treated at each facility.
Do you know and implement the Geriatric Assessment (GA)? GA was de ned as a method to comprehensively evaluate physical, mental, and social functions.
Items to be evaluated when deciding surgical treatment policy for elderly cancer patients We asked respondents to respond to the following 11 items using a 3-point scale of "very important," "important," or "not important: 1) age; 2) performance status (PS); 3) judgment of the anesthesiologist; 4) results of general preoperative examinations; 5) comorbidities; 6) social factors such as institutionalization or living alone; 7) complications of dementia; 8) overall evaluation of the elderly; 9) severity of sarcopenia; 10) guidelines; and 11) family wishes.
Preoperative evaluations performed and what methods of evaluation were used? Data on whether the following eight preoperative assessment items were performed and how they were assessed were requested: 1) physical function; 2) comorbidities; 3) medications; 4) nutritional status; 5) cognitive function; 6) depression; 7) social support status; and 8) risk of delirium.

Statistical analysis
Among the survey items, to examine associations of "presence of GA awareness" with "years of experience as a physician," "whether the respondent had obtained a medical specialty," "whether the respondent had obtained Ph.D.," "the facility to which the respondent belonged," "the specialty of the respondent," and "the annual percentage of elderly treated at each facility," chi-squared tests were used. The level of statistical signi cance was set at less than 5%. IBM SPSS Statistics 27 (IBM, Armonk, NY, USA) was used for all statistical analyses.

Ethics
All study protocols were conducted with the approval of The Research Committee of the University of Fukui (approval number 20190123). Since this was a retrospective observational study, the need for written informed consent was waived. Instead of written informed consent, information about this survey was published and participants were given the right to opt out. This survey was conducted in accordance with the Declaration of Helsinki. All methods were performed in accordance with the approved guidelines and regulations.

Results
We asked each department of the 436 facilities to cooperate in completing the questionnaire, and received responses from 245 facilities (56%), with a total of 941 department heads. Of these, valid responses were obtained from 919 department heads.

Background characteristics of respondents (Figs. 1-3).
In terms of institutional classi cations, 594 (64.6%) department heads belonged to 66 medical education institutions such as university hospitals, 323 (35.2%) belonged to 177 hospitals other than medical education institutions, and one each belonged to a clinic, or government institution or company (including industrial physicians). Gastrointestinal surgery was the most common department, with 122 respondents (13.3%). The average percentages of patients <65 years old, 65-74 years old, 75-84 years old, and ³85 years old were 36.3%, 32.5%, 25.1%, and 9.0%, respectively. The average proportion of cancer surgery patients ³65 years old was higher in medical education institutions than other hospitals (66.2% vs 61.4%, p = 0.001). GA (Fig. 4, Table 1).
Of the 919 valid responses, 195 department heads (21%) answered they knew about GA. Among those, 103 (11% of the total) answered they were actually performing GA. Furthermore, only 30 respondents indicated that they were implementing GA in all cases.
The chi-squared test was used to examine whether GA awareness was associated with respondent background.
Respondents from medical education institutions were signi cantly less likely to be aware of GA (18.5%) than those from other hospitals (26.3%; P=0.006). This result can be interpreted as meaning that medical education institutions have a lower awareness of GA. With regard to the relationship between whether a respondent had obtained a Ph.D. degree and GA, the results can be interpreted as indicating that doctors who had obtained a Ph.D.
degree were more aware of GA (P=0.015). In addition, the more years of experience a physician had, the more likely they were to be aware of GA. No signi cant relationships were apparent between specialty certi cation, percentage of institutional elderly treated, and awareness of GA. A signi cant association was seen between GA awareness and department type (P<0.001), with awareness higher in departments of gastrointestinal surgery and urology, and lower in departments of orthopedics and dermatology/plastic surgery. Regarding the implementation of GA, the 103 respondents who answered that they were implementing GA were 47/278 (14.2%) of medical education institutions and 57/538 (9.6%) of other hospitals (p = 0.033). Medical education institutions were implementing more GA. Items considered important when deciding on a treatment plan ( Table 2).
Most respondents answered that most items were "very important" or "important". In particular, >50% of all respondents answered "very important" for PS, preoperative examination, and comorbidities. Social factors such as age, institutionalization and solitary residence, comprehensive evaluation of the elderly, severity of sarcopenia, and guidelines were "not important" for >10% of all respondents. Of these, 25% and 18% chose "not important" for GA and sarcopenia, respectively. We asked respondents to, "Please select the importance of each of the following assessment items when deciding surgical treatment methods for elderly cancer patients": 1) age; 2) PS; 3) judgment of anesthesiologist; 4) preoperative examination before treatment; 5) complications; 6) social background such as institutionalization or living alone; 7) presence of dementia; 8) overall evaluation of elderly patients; and 8) overall assessment of the elderly; 9) severity of sarcopenia; 10) guidelines; and 11) wishes of the family. Preoperative assessment items and methods of evaluation (Table 3, Figure 5).
Physical condition and comorbidity were assessed in almost all cases, followed by social support, nutritional status, and cognitive function in >80% of cases. Delirium risk was assessed in 39% of cases, and mood state in 19% of cases. The speci c methods of assessment most frequently used for each item were PS for physical function (86%), history taking for comorbidity (99%), body mass index (BMI) for nutritional status (75%), the revised Hasegawa Dementia Scale (HDS-R) for cognitive function (35%), usual patient background (assessment by nurses on admission) for social support status (86.5%), and con rming a history of agitation and hyperactivity for risk of delirium (32.1%). We asked respondents to indicate whether participants performed the following assessments before surgery: 1) physical condition; 2) con rmation of complications; 3) nutritional condition; 4) medication; 5) cognition; 6) mood; 7) social support; and 8) delirium. (Multiple responses accepted)

Discussion
This is the rst large-scale survey to investigate the current status of medical care for elderly cancer surgery patients in Japan. Of these, survey cooperation was obtained from 245 facilities, representing a majority of the 436 facilities nationwide, including high-volume centers for cancer care. The survey revealed that not only is use of the GA not widespread, but awareness of GA also appears to be declining in medical education institutions. At the same time, the physical aspects of GA, such as assessment of physical functions and comorbidities, were widely conducted in each department with a common understanding, but assessment of nutritional status, cognitive functions, emotions/moods (depression, delirium), and social/economic status were not conducted su ciently, and implementation varied among departments. There are several possible factors that contributed to the differences in awareness and implementation of GA between medical education institutions and other hospitals. First, the implementation of GA to oncologic surgery in Japan has a strong research aspect. Some university hospitals in Japan are conducting clinical research of GA, and preoperative GA is routinely performed on a facility basis. Secondly, university hospitals, which are medical education institutions, tend to have very high specialties in each clinical department, and generally there are few opportunities to hold joint conferences with internal medical departments. Compared to university hospitals, small-scale community hospitals are expected to hold more multidisciplinary and other occupational conferences, which may contribute to raising awareness of GA. In addition, as the background of the respondents, the response rate other than medical education institutions was about half that of medical education institutions. Thus, some of the department heads other than medical education institutions who participated in this survey may include a larger group of more interested in geriatrics, which may raise awareness of GA.
The physiological functions of various organs decline in the elderly, and their ability to tolerate treatment is reduced due to the presence of many comorbidities. Both of these factors tend to increase and prolong treatment- In a survey conducted by the International Society of Geriatric Oncology (SIOG), 80% of surgeons responded that cancer surgery has no de nitive age limits [ 10 ]. Elderly cancer patients can be considered for the same treatment as non-elderly cancer patients. In order to make such decisions, we believe that conducting preoperative evaluations based on GA that can identify problems speci c to elderly patients is important.
However, the lack of high-quality studies that have veri ed the usefulness of GA in elderly cancer surgery patients, there are currently no guidelines recommending GA as a preoperative evaluation. In 2017, Huisman et al. compiled nine systematic reviews of GA in elderly cancer surgery patients. All GA domains except polypharmacy are associated with postoperative adverse events and prognosis, and in particular, the domain of PS and comorbidities and the evaluation of frailty by GA tools are important for prognosis prediction [ 11 ]. Although GA observational studies and case control studies in elderly cancer surgery patients are increasing, differences in study population background, selection bias, surgical techniques and evaluation tools used, and endpoint settings make it di cult to build the evidence. In such a situation, four randomized control studies as new evidence for GA were reported at the ASCO 2020 annual meeting [12][13][14][15]. Three of the four studies were chemotherapeutic studies and the remaining was a surgical study; all showed the usefulness of the GA.
Although the utility of GA has been recognized, one reason for its lack of widespread adoption may be that it is considered impractical due to the complexity of the assessment items. The SIOG has proposed simple screening methods such as the Geriatric-8, the Flemish version of the Triage Risk Screening Tool, and the Vulnerable Elders Survey- 13 [ 16 ]. The fundamental problem, however, may be a lack of recognition about the importance of geriatrics. This is an issue that goes to the core of the legal system, geriatric education, and lifelong learning in a nation such as Japan. This survey revealed that awareness of GA is declining in medical education institutions in Japan, and there is room for intervention.
Medical education in Japan has long been considered to be lagging behind that of Western countries. Nishijima et al. clari ed the current status of lack of geriatric medicine education in Japan [ 17 ]. In particular, due to the historical background of medical care being developed for emergency and specialty care, education in the eld of geriatrics has lagged well behind, and medical care adapted to the elderly has often been thought to have been given insu cient consideration. Especially in Europe and the United States, the importance of geriatrics has long been recognized and is being re ected in actual clinical practice. In France, legislation has been established to support the lives of the elderly, and in addition to the development of a geriatric education system, a network for the treatment of the elderly has been established, consisting of geriatric outpatient clinics, day hospitalizations, geriatric support teams, acute care wards, and recovery hospitals. In the United States, a department of geriatrics has been established in basically all university hospitals, and comprehensive medical care is provided by a team consisting of various professionals specializing in geriatrics. On the other hand, only about 30% of universities in Japan have geriatric medicine departments, and education is in reality provided by a mixture of several elds [ 17 ].
As a step toward developing approaches to cope with the super-aging society in Japan, the 2016 revision of the The strengths of this research is that it is the rst large-scale research in Japan targeting surgical departments.
Secondary, there is little regional difference, and responses are obtained from the majority of facilities including the city centers and rural areas. Third, we were able to minimize data loss by re ning the web response system. As a limitation, rst, there was a large difference in the number of respondents between medical education institutions and other hospitals. In particular, respondents from hospitals other than medical institutions may include more doctors working on geriatric oncology, which may have caused a statistically signi cant difference in GA awareness. Secondly, the real respondents may not have been each department head. Although this study requested a survey of each department head at each institution, another doctor representing the department may responded without the intention of the department heads. There is a possibility that the number of years of experience as a doctor and the PhD acquisition rate do not accurately re ect the data of the department head.
Third, GA implementation and postoperative outcome have not been examined. In order to clarify this, more detailed survey is required, which puts a heavy burden on the respondents. Since the purpose of this research was to investigate the current state of preoperative evaluation for elderly cancer patients, postoperative outcome was not set as a survey item.
In conclusion, this large questionnaire survey on the current status and problems of elderly cancer surgery patients in Japan revealed not only that GA is not widespread, but also that the level of awareness of GA in medical education institutions is low. The practice of geriatrics and its education seem to be in question. To address this situation, accumulation of evidence on the treatment of elderly cancer patients in Japan and establishment of treatment guidelines are urgent tasks. Based on the present results, the relationship between GA and postoperative prognosis for elderly cancer surgery patients needs to be veri ed in Japan to establish appropriate methods of pretreatment evaluation for elderly cancer patients.
Declarations Figure 1 Background    GA recognition and implementation rates, and assessment tools a) GA recognition rate. b) GA implementation rate. c) GA evaluation tools. (Multiple responses accepted) GA geriatric assessment