90 is Just a Number for Whipple Surgery
As a young soldier, Gus Snare stopped through the University of Chicago medical campus in 1942, on his way to the South Pacific, to process paperwork on a physical exam.
He had no reason to revisit this or any other hospital for the next 68 years. He came home from World War II, married a nurse and went back to his job at a stone quarry south of Chicago. He was so active and healthy, he almost never even caught a cold.
So when he had a sudden loss of appetite last fall, the Crete, Illinois, native was puzzled. "I was feeling bad. Even water didn’t look good to me," he said. His physicians at the University of Chicago Medicine soon found a mass on his pancreas that they later confirmed was bile duct cancer. The cancer was serious: It was located at the Ampulla of Vater, a nipple-like projection into the small intestine. All secretions from the pancreas and bile duct enter the small intestine at that point. Cancer in that area typically creates a blockage, causing those secretions to build up in the bloodstream to dangerous levels.
To survive, Snare would need parts of his stomach, duodenum, pancreas, bile duct and gallbladder removed -- a major surgery often called a Whipple procedure.
"It’s rare that we find a 90-year-old who is fit enough to tolerate a Whipple procedure," said Kevin Roggin, MD, associate professor of surgery and cancer research. "Many patients whom we see in that age range have other medical conditions and are often not candidates for these major operations."
Such comorbidities, like dementia, renal failure, heart disease and diabetes, can make surgery or cancer treatment too difficult for the body and lead to negative outcomes for the patient. If surgery or cancer treatment is too risky for an older patient, physicians often will try to ease the patient’s suffering with palliative care.
However, Roggin and William Dale, MD, PhD, section chief for geriatrics and palliative medicine, have made cases like Snare’s the object of intense study. They are finding that older patients who are independent and healthy can recover from difficult operations.
"When we see a patient who can withstand the stress of surgery, we’d like to be able to offer him some meaningful and beneficial treatment," Roggin said.
Snare’s three children insisted that he would survive an operation. Without it, they knew, he had only a matter of months to survive.
So Snare went to the Specialized Oncology Care & Research in the Elderly (SOCARE), Dale’s geriatric-oncology clinic, for an evaluation. Dale wanted to determine Snare’s life expectancy with and without a surgery.
"As a geriatrician, I don’t think about chronological age, but rather physiological age," Dale said.
He tested Snare’s balance, the strength of his legs, how fast he could walk. He checked Snare’s cognition. He looked for signs of undiagnosed conditions that might show up in the stress of surgery. He asked Snare about his support network to see if he had friends and family to help him recover.
"We'll ask: ‘Can you go shopping? Can you get where you need to go? Can you do your finances?’" Dale said. "If all those things fall into place, 90 is just an arbitrary number."
When the geriatric stress test was done, Snare came out looking good. "Gus Snare was an extreme case because he is so healthy for his age," Dale said.
Together, Dale and Roggin determined that they could offer Snare more than palliative care. "We felt that surgery was a realistic option," Roggin said.
Snare was ready. Last October, Roggin performed a Whipple procedure on the oldest patient ever to have the procedure at the medical center.
Eight and a half hours later, the surgery was a success. Roggin completely removed a grape-sized tumor from Snare’s pancreas and sent him to recover with a team of enthusiastic nurses.
"Everyone thought he was an inspiration. All the nurses loved him," said Alaine Kamm, RN, APN. "Since he was a World War II veteran, we knew he could come through surgery, which can be like another war."
The three-week recovery was complicated, but Snare indeed won the war. He is eating his favorite foods again, walking around big shopping malls and looking forward to camping this spring. If everything goes as planned, he’ll fish near the Canadian border with some of his lifelong friends.
"There is a school of thought that these operations are too difficult for older patients to tolerate," Roggin said. "In fact, more than one-third of older patients are never referred to a surgical oncologist to discuss curative treatment options. The pessimistic observer might ask, ‘Why did you do that to a 90-year-old man?’ But seeing these patients recover back to their baseline after such major operations, and offering them a chance to survive a difficult cancer, is extremely gratifying. Only time will tell if we have successfully cured Mr. Snare’s cancer, but we at least gave him hope for the future."
Roggin and Dale are involved in a long-term study in which they use a comprehensive assessment of geriatric patients to identify undiagnosed frailty that may affect perioperative outcomes. They recently enrolled their 100th patient on this longitudinal outcomes study and hope soon to be able to combine this clinical information with sophisticated genomic data to predict outcomes and tumor biology.