Research Article| Volume 1, ISSUE 2, P57-65, October 2010

Which elements of a comprehensive geriatric assessment (CGA) predict post-operative complications and early mortality after colorectal cancer surgery?



      To identify independent predictors of post-operative complications and early mortality in elderly patients operated for colorectal cancer from a comprehensive geriatric assessment [CGA] and Eastern Cooperative Oncology Group performance status [PS].

      Patients and Methods

      Patients ≥70 years electively operated for all stages of colorectal cancer from 2006 to 2008 in three hospitals were consecutively included. CGA addressed the following domains pre-operatively: personal and instrumental activities of daily living [IADL], comorbidity, polypharmacy, nutrition, cognition, and depression. The associations between elements of CGA as well as PS and morbidity and mortality were analyzed using multivariate regression models.


      Patients (182) with a median age of 80 years (range, 70–94 years) were included. Severe comorbidity was an independent predictor of severe complications (odds ratio [OR] 5.62; 95% CI 2.18 to 14.50) and early mortality (hazard ratio [HR] 2.78; 95% CI 1.50 to 5.17). IADL-dependency and depression were predictors of any complication (OR 4.02; 95% CI 1.24 to 13.09 and OR 3.68; 95% CI 0.96 to 14.08, respectively) while impaired nutrition predicted early mortality (HR 2.39, 95% CI 1.24 to 4.61). When added to the models, PS independently predicted both morbidity and early mortality, and PS was a more powerful predictor than IADL-dependency, depression, and impaired nutrition.


      In elderly patients with colorectal cancer, severe comorbidity, IADL-dependency, depression, and impaired nutrition seem to be the most important CGA-elements predictive of post-operative complications and early mortality. As PS predicts all outcomes, a consistent use of PS in studies of cancer surgery is recommended.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Geriatric Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Repetto L.
        • Fratino L.
        • Audisio R.A.
        • Venturino A.
        • Gianni W.
        • Vercelli M.
        • et al.
        Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study.
        J Clin Oncol. 2002; 20: 494-502
        • Extermann M.
        • Overcash J.
        • Lyman G.H.
        • Parr J.
        • Balducci L.
        Comorbidity and functional status are independent in older cancer patients.
        J Clin Oncol. 1998; 16: 1582-1587
        • Longo W.E.
        • Virgo K.S.
        • Johnson F.E.
        • Oprian C.A.
        • Vernava A.M.
        • Wade T.P.
        • et al.
        Risk factors for morbidity and mortality after colectomy for colon cancer.
        Dis Colon Rectum. 2000; 43: 83-91
        • Reuter N.P.
        • Macgregor J.M.
        • Woodall C.E.
        • Sticca R.P.
        • William C.
        • Helm M.B.
        • et al.
        Preoperative performance status predicts outcome following heated intraperitoneal chemotherapy.
        Am J Surg. 2008; 196: 909-913
        • Ouellette J.R.
        • Small D.G.
        • Termuhlen P.M.
        Evaluation of Charlson-Age Comorbidity Index as predictor of morbidity and mortality in patients with colorectal carcinoma.
        J Gastrointest Surg. 2004; 8: 1061-1067
        • Bozzetti F.
        • Gianotti L.
        • Braga M.
        • Di Carlo V.
        • Mariani L.
        Postoperative complications in gastrointestinal cancer patients: the joint role of the nutritional status and the nutritional support.
        Clin Nutr. 2007; 26: 698-709
        • Fukuse T.
        • Satoda N.
        • Hijiya K.
        • Fujinaga T.
        Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients.
        Chest. 2005; 127: 886-891
        • Sharma A.
        • Sharp D.
        • Walker L.
        • Monson J.
        Predictors of early postoperative quality of life after elective resection for colorectal cancer.
        Ann Surg Oncol. 2007; 14: 3435-3442
        • Audisio R.A.
        • Pope D.
        • Ramesh H.S.
        • Gennari R.
        • van Leeuwen B.L.
        • West C.
        • et al.
        Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study.
        Crit Rev Oncol Hematol. 2008; 65: 156-163
        • Wolters U.
        • Stützer H.
        • Keller H.W.
        • Schroder U.
        • Pichlmaier H.
        Colorectal cancer—a multivariate analysis of prognostic factors.
        Eur J Surg Oncol. 1996; 22: 592-597
        • Makela J.T.
        • Kiviniemi H.
        • Laitinen S.
        Survival after operations for colorectal cancer in patients aged 75 years or over.
        Eur J Surg. 2000; 166: 473-479
        • Kristjansson S.R.
        • Nesbakken A.
        • Jordhoy M.S.
        • Skovlund E.
        • Audisio R.A.
        • Johannessen H.O.
        • et al.
        Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study.
        Crit Rev Oncol Hematol. 2009;
        • Mahoney F.I.
        • Barthel D.W.
        Functional evaluation: the Barthel Index.
        Md State Med J. 1965; 14: 61-65
        • Lincoln N.B.
        • Gladman J.R.
        The extended activities of daily living scale: a further validation.
        Disabil Rehabil. 1992; 14: 41-43
        • Basso U.
        • Monfardini S.
        Multidimensional geriatric evaluation in elderly cancer patients: a practical approach.
        Eur J Cancer Care (Engl). 2004; 13: 424-433
        • Miller M.D.
        • Paradis C.F.
        • Houck P.R.
        • Mazumdar S.
        • Stack J.A.
        • Rifai A.H.
        • et al.
        Rating chronic medical illness burden in geropsychiatric practice and research: application of the Cumulative Illness Rating Scale.
        Psychiatry Res. 1992; 41: 237-248
        • Salvi F.
        • Miller M.D.
        • Grilli A.
        • Giorgi R.
        • Towers A.L.
        • Morichi V.
        • et al.
        A manual of guidelines to score the modified cumulative illness rating scale and its validation in acute hospitalized elderly patients.
        J Am Geriatr Soc. 2008; 56: 1926-1931
        • Massa E.
        • Madeddu C.
        • Astara G.
        • Pisano M.
        • Spiga C.
        • Tanca F.M.
        • et al.
        An attempt to correlate a “Multidimensional Geriatric Assessment” (MGA), treatment assignment and clinical outcome in elderly cancer patients: results of a phase II open study.
        Crit Rev Oncol Hematol. 2008; 66: 75-83
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatry Res. 1975; 12: 189-198
        • Yesavage J.A.
        • Brink T.L.
        • Rose T.L.
        • Lum O.
        • Huang V.
        • Adey M.
        • et al.
        Development and validation of a geriatric depression screening scale: a preliminary report.
        J Psychiatry Res. 1982; 17: 37-49
        • Guigoz Y.
        The Mini Nutritional Assessment (MNA) review of the literature—what does it tell us?.
        J Nutr Health Aging. 2006; 10: 466-485
        • Viktil K.K.
        • Blix H.S.
        • Moger T.A.
        • Reikvam A.
        Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems.
        Br J Clin Pharmacol. 2007; 63: 187-195
        • Oken M.M.
        • Creech R.H.
        • Tormey D.C.
        • Horton J.
        • Davis T.E.
        • McFadden E.T.
        • et al.
        Toxicity and response criteria of the Eastern Cooperative Oncology Group.
        Am J Clin Oncol. 1982; 5: 649-655
        • Clavien P.A.
        • Sanabria J.R.
        • Strasberg S.M.
        Proposed classification of complications of surgery with examples of utility in cholecystectomy.
        Surgery. 1992; 111: 518-526
        • Balducci L.
        • Ershler W.B.
        Cancer and ageing: a nexus at several levels.
        Nat Rev Cancer. 2005; 5: 655-662
        • Morello E.
        • Sandri R.
        • Monfardini S.
        Enough rehabilitation for our elderly cancer patients?.
        Eur J Cancer. 2008; 44: 2338-2339
        • Hamel M.B.
        • Henderson W.G.
        • Khuri S.F.
        • Daley J.
        Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery.
        J Am Geriatr Soc. 2005; 53: 424-429
        • Turrentine F.E.
        • Wang H.
        • Simpson V.B.
        • Jones R.S.
        Surgical risk factors, morbidity, and mortality in elderly patients.
        J Am Coll Surg. 2006; 203: 865-877
        • Leung J.M.
        • Dzankic S.
        Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients.
        J Am Geriatr Soc. 2001; 49: 1080-1085
        • Smith P.W.
        • Wang H.
        • Gazoni L.M.
        • Shen K.R.
        • Daniel T.M.
        • Jones D.R.
        Obesity does not increase complications after anatomic resection for non-small cell lung cancer.
        Ann Thorac Surg. 2007; 84: 1098-1105
        • Lemmens V.E.
        • Janssen-Heijnen M.L.
        • Houterman S.
        • Verheij K.D.
        • Martijn H.
        • d.P.-F. van
        • et al.
        Which comorbid conditions predict complications after surgery for colorectal cancer?.
        World J Surg. 2007; 31: 192-199
        • Tan K.Y.
        • Kawamura Y.
        • Mizokami K.
        • Sasaki J.
        • Tsujinaka S.
        • Maeda T.
        • et al.
        Colorectal surgery in octogenarian patients—outcomes and predictors of morbidity.
        Int J Colorectal Dis. 2009; 24: 185-189
        • Yancik R.
        • Wesley M.N.
        • Ries L.A.
        • Havlik R.J.
        • Long S.
        • Edwards B.K.
        • et al.
        Comorbidity and age as predictors of risk for early mortality of male and female colon carcinoma patients: a population-based study.
        Cancer. 1998; 82: 2123-2134
        • Iversen L.H.
        • Norgaard M.
        • Jacobsen J.
        • Laurberg S.
        • Sorensen H.T.
        The impact of comorbidity on survival of Danish colorectal cancer patients from 1995 to 2006—a population-based cohort study.
        Dis Colon Rectum. 2009; 52: 71-78
        • Lawrence V.A.
        • Hazuda H.P.
        • Cornell J.E.
        • Pederson T.
        • Bradshaw P.T.
        • Mulrow C.D.
        • et al.
        Functional independence after major abdominal surgery in the elderly.
        J Am Coll Surg. 2004; 199: 762-772
        • Greene N.H.
        • Attix D.K.
        • Weldon B.C.
        • Smith P.J.
        • McDonagh D.L.
        • Monk T.G.
        Measures of executive function and depression identify patients at risk for postoperative delirium.
        Anesthesiology. 2009; 110: 788-795
        • Whooley M.A.
        • de Jonge P.
        • Vittinghoff E.
        • Otte C.
        • Moos R.
        • Carney R.M.
        • et al.
        Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease.
        JAMA, J Am Med Assoc. 2008; 300: 2379-2388
        • Asteria C.R.
        • Gagliardi G.
        • Pucciarelli S.
        • Romano G.
        • Infantino A.
        • La T.F.
        • et al.
        Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery.
        Tech Coloproctol. 2008; 12: 103-110
        • Veliz-Reissmuller G.
        • Aguero T.H.
        • van der L.J.
        • Lindblom D.
        • Eriksdotter J.M.
        Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery.
        Aging Clin Exp Res. 2007; 19: 172-177
        • Inouye S.K.
        • Bogardus S.T.
        • Charpentier P.A.
        • Leo-Summers L.
        • Acampora D.
        • Holford T.R.
        • et al.
        A multicomponent intervention to prevent delirium in hospitalized older patients.
        N Engl J Med. 1999; 340: 669-676


      Dr. Kristjansson is a research fellow at the Department of Geriatric Medicine, Oslo University Hospital, Ullevål and at the University of Oslo. She is specializing in internal medicine and geriatric medicine. The focus of her research is the integration of a comprehensive geriatric assessment in the pre-operative evaluation of elderly cancer patients, and the identification of frailty in elderly patients.