Palliative geriatric assessment in selection of older patients with resectable pancreatic ductal adenocarcinoma for surgical treatment

Palliative geriatric assessment in selection of older patients with resectable pancreatic ductal adenocarcinoma for surgical treatment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Palliative geriatric assessment in selection of older patients with resectable pancreatic ductal adenocarcinoma for surgical treatment Lucia Dzurillová, Andrea Škripeková, Jan Smrek, Katarína Gazdíková, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9346804/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Surgical treatment of older patients with resectable pancreatic ductal adenocarcinoma (PDAC) is limited by comorbidities, frailty, and risk of postoperative functional deterioration. The study aimed to evaluate factors influencing shared decision-making in treatment allocation of geriatric patients with resectable PDAC and to compare survival and postoperative outcomes according to treatment strategy. Methods Patients older than 65 years with primary resectable PDAC were prospectively enrolled. Patients were either directly indicated for surgery by a surgeon or referred for comprehensive palliative geriatric assessment when surgical fitness was uncertain. Patients assessed as fit underwent pancreatic resection, whereas unfit patients received oncologic and palliative treatment. Clinical, functional, and quality-of-life parameters were analysed. Multivariate logistic regression included age-adjusted Charlson Comorbidity Index (aaCCI), Instrumental Activities of Daily Living (IADL), Karnofsky Performance Status (KPS), and selected EORTC QLQ-C30 variables. Results Sixty-nine patients were included; 19 directly selected for surgery (Control group- C), 22 assessed as fit after geriatric evaluation (Intervention group - I), and 28 assigned to palliative treatment (Palliative group- P). Median overall survival (mOS) did not significantly differ between groups (7.5 vs. 14.26 vs. 16.3 months; P vs I, p = 0.054; I vs C, p = 0.63; P vs C, p = 0.058). When we compared mOS of all operated patients (C + I) versus palliative group, the difference reached statistical significance (16,3 months vs 7.5 monhts, HR = 1.78, 95% CI 1.08–2.92, p = 0.02). Length of intensive care unit stay, severe postoperative complications, and chemotherapy administration were comparable. Significant differences between intervention and palliative groups were found in aaCCI (p = 0.016), IADL (p = 0.025), KPS (p = 0.001), fatigue (p = 0.042), and physical functioning (p = 0.028). Multivariate analysis identified aaCCI and IADL as independent predictors of treatment allocation. Conclusions Comprehensive palliative geriatric assessment supports shared decision-making and may help identify older patients suitable for pancreatic surgery despite initial concerns regarding frailty. aaCCI and IADL represent practical clinical parameters for surgical selection; further validation in larger cohorts is required. pancreatic cancer older patients geriatric assessment pancreatic surgery frailty decision-making Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Pancreatic cancer accounted for 510,990 new cases worldwide in 2022 and its incidence is expected to rise to 998,660 by 2050 according to GLOBOCAN (Global Cancer Observatory) data [1]. Among gastrointestinal malignancies, pancreatic cancer shows one of the fastest rising trends in both incidence and mortality [1]. The median age at diagnosis is 71 years, reflecting the growing impact of pancreatic cancer in the aging population [1]. Despite this demographic reality, elderly patients remain underrepresented in clinical trials evaluating pancreatic cancer treatment, with the median age of enrolled patients reported to be approximately six years lower than that observed in the general population [2]. Consequently, evidence guiding treatment decisions in geriatric patients remains limited. Pancreatic surgery is a technically demanding procedure associated with postoperative complication rates approaching 30% and perioperative mortality 1–3%, even in high-volume centers [3]. Current studies addressing treatment decision-making in older patients mainly focus on postoperative outcomes and survival after surgery. [4, 5, 6]. However, data describing treatment trajectories and outcomes of patients deemed unfit for surgical intervention remain scarce [4, 5, 6]. Comprehensive geriatric assessment and other measures has been proposed as a tool to evaluate functional reserve, frailty, and treatment tolerance beyond chronological age [7, 8, 9]. Integration of palliative care principles into the preoperative evaluation may further support shared decision-making by incorporating patients’ functional status, symptom burden, and individual goals of care. Nevertheless, the role of structured palliative geriatric assessment in selecting elderly patients with resectable pancreatic ductal adenocarcinoma for surgery has not been sufficiently explored. The aim of this study was to evaluate factors influencing shared decision-making in treatment allocation of older patients with resectable pancreatic ductal adenocarcinoma and to compare survival and treatment outcomes according to treatment strategy. Material and Methods 2.1 Study design and patients This single-center study was conducted at the National Cancer Institute, Bratislava, Slovakia, between 2019 and 2024. The study included patients older than 65 years with newly diagnosed primary resectable pancreatic ductal adenocarcinoma (PDAC). Patients were initially evaluated by a pancreatic surgeon. Patients considered clearly fit were directly indicated for pancreatic surgery (control group, C). When surgical fitness was uncertain, patients were referred to an outpatient oncologic palliative care clinic for comprehensive palliative geriatric assessment. The study cohort consisted of 50 consecutive patients referred for palliative geriatric assessment prior to planned surgery and 19 patients who underwent surgery without such assessment (Fig. 1 ). The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee. 2.2 Palliative geriatric assessment and intervention The outpatient oncologic palliative care clinic provides early integrated palliative care for cancer patients at all disease stages. The assessment was performed by a palliative care physician who is also a medical oncologist. Comprehensive palliative geriatric assessment included: detailed medical history and symptom evaluation, physical examination, Instrumental Activities of Daily Living (IADL), age-adjusted Charlson Comorbidity Index (aaCCI), Karnofsky Performance Status (KPS), pain intensity assessed using Numeric Rating Scale, body mass index (BMI), echocardiography and pulmonary function examination, laboratory testing (liver enzymes, cholinesterase, bilirubin, albumin, CRP, CA19-9, creatinine). Patients completed quality-of-life questionnaires EORTC QLQ-C30 (version 3) and EORTC PAN26 at the initial assessment [10]. Following evaluation, a structured consultation with the patient and family members focused on disease understanding, treatment options, risks and benefits, symptom burden, and individual goals of care. Shared decision-making was used to determine the treatment strategy. Patients assessed as fit underwent pancreatic resection (intervention group, I). Patients considered unfit received oncologic treatment and specialist palliative care (palliative group, P). 2.3 Study outcomes and eligibility criteria Patients eligible for inclusion were aged ≥ 65 years, had newly diagnosed resectable pancreatic ductal adenocarcinoma, were evaluated by a pancreatic surgeon at our institution, and provided informed consent for palliative geriatric assessment. Exclusion criteria included age < 65 years, non-PDAC histology, borderline resectable or unresectable disease, and patient refusal of palliative geriatric assessment. The primary endpoint was overall survival among three groups of geriatric patients with resectable PDAC: patients directly selected for surgery by surgeon (control group, C), (n = 19), patients assessed as fit for surgery after palliative geriatric assessment (intervention group, I), (n = 22), patients considered unfit or unwilling to undergo surgery and treated with palliative care (palliative group, P), (n = 28). Overall survival was defined as time from date of diagnosis to death from any cause. Secondary endpoints included postoperative complications, administration of oncologic treatment, quality-of-life parameters, length of stay at intensive care unit (ICU), and rates of adjuvant or palliative chemotherapy. Postoperative complications were classified according to the Clavien–Dindo classification [11]. 2.3. Data collection Clinical data were obtained from the hospital information system of the National Cancer Institute. Collected variables included demographic characteristics, laboratory parameters (albumin, cholinesterase, CA19-9), functional status (IADL, aaCCI, quality of life questionnaires), surgical characteristics, postoperative complications, length of stay at ICU, administration of adjuvant or palliative chemotherapy and overall survival. Patients were followed from the date of diagnosis until death or 31st December 2024, whichever occurred first. 2.4. Statistical analysis Descriptive statistics were used to summarize baseline characteristics. Continuous variables were expressed as median and interquartile range (IQR), and categorical variables as absolute numbers and percentages. Each group was characterized by calculating proportional representation, median and interquartile range in each category. Overall survival was analysed using Kaplan–Meier curves and compared between groups using the log-rank test. Due to moderate sample size, selected clinically relevant variables were prescreened using univariate analysis with Bonferroni correction for multiple testing. Variables reaching statistical significance were entered into multivariate logistic regression models to identify predictors of treatment allocation (P vs I groups). The observed follow-up time statistics was computed directly from all observed follow-up times, including the censored cases. The association between selected variables and survival was evaluated using multivariate Cox proportional hazards models. Statistical significance was defined as p < 0.05. Baseline characteristics were calculated in the software Numbers version 6.1 (Apple) and statistical testing of groups differences using software Python 3.9.12 with modules scipy 1.11.1., scikit-survival 0.21.0, scikit-learn 1.2.2, statsmodels 0.13.2. Results 3.1 Patients characteristics A total of 69 patients were included in the analysis: 36 men (53%), 33 women (47%). Median age was 69 (range 65–77) years in Control group (C), 74 years (range 65–84 years) in Intervention group (I) and 77 (range 69–86 years) in Palliative group (P). Basic demographics characteristics are summarized in Table 1 . 3.2. Overall survival The median follow-up times were 6.5 months (range 0.9–52.6), 12.7 (range 0.9–63.5) and 16.3 (range 1.1–78.9) months for P, I and C groups respectively. Median overall survival (mOS) was 7.5 months (IQR 2.96 to 15.6 months) in palliative group, 14.3 months (IQR: 6.0 to 26.46 months) in intervention group, and 16.3 months (IQR: 8.5 to 25.6 months) in the control group. Kaplan-Meier curves of survival in groups I, P, C are in Fig. 2 . Log-rank testing showed no statistical differences between groups (P vs I, HR = 1.78, 95% CI 0.97–3.27, p = 0.054; I vs C, HR = 0.85, 95%CI. 0.44–1.64, p = 0.63; P vs C, HR = 1.72, 95%CI. 0.96–3.09, p = 0.058). When the C and I groups were combined and compared with the P group, the difference reached statistical significance: mOS C + I 16,3months (IQR: 7.3 to 26.5months) vs mOS P 7.5 months (IQR 2.96 to 15.6 months), HR = 1.78, 95% CI 1.08–2.92, p = 0.02. Kaplan-Meier curves of survival in C + I vs P groups are in Fig. 3 . 3.3. Parameters associated with treatment allocation Comparison between intervention and palliative groups demonstrated significant differences in several parameters obtained during palliative geriatric assessment (Table 1 and Fig. 4 ). Significant variables included: age-adjusted Charlson Comorbidity Index (aaCCI) Instrumental Activities of Daily Living (IADL) Karnofsky Performace Status EORCT QLQ-C30 Physical Functionig EORTC QLQ-C30 Fatigue (All p < 0.05). Median aaCCI was 6 in both I and C group vs 7.5 in P group (p = 0.016), median IADL was 8 in I vs 6 in P group (p = 0,025), median Karnofsky performance status was 100% in I group vs 80% in P group (p = 0.001). We compared all functional and symptom scales and also global health status in quality of life questionnaires EORTC QLQ-C30. We found significant differences only in EORTC QLQ C30 Physical Functioning scale with higher average score in I group 82.4 vs P group 52.4 (p = 0.028), and in the Fatigue scale with lower average score in I group 30.6 vs P group 60.9 (p = 0.042). 3.4 Oncologic treatment Adjuvant chemotherapy administration did not differ between C and I group (Fisher’s exact test p = 1.00), 6 (27%) patients in I group and 6 (31%) patients in C group received adjuvant chemotherapy,16 (73%) patients in intervention group and 13 (69%) patients in control group did not receive adjuvant chemotherapy due to decline in performance status. Palliative chemotherapy was administered in 9 patients (32%) in the palliative group, 7 patients (32%) in the intervention group, and 4 patients (21%) in the control group, without statistically significant differences (p > 0.05). 3.5 Surgical outcomes Length of stay in the intensive care unit did not differ significantly between surgical groups (Mann–Whitney U test p = 0.97). The rate of postoperative complications classified according to Clavien–Dindo was also comparable between groups (p = 0.40). 3.6 Multivariate analysis Multivariate logistic regression models identified aaCCI and IADL as independent predictors of treatment allocation between intervention and palliative groups. Additional variables demonstrated collinearity and were excluded from final models. A logistic model based solely on aaCCI showed limited predictive performance when applied to the control group (classification accuracy 53%), suggesting that isolated comorbidity assessment is insufficient without comprehensive geriatric evaluation. Cox proportional hazards modelling including IADL, aaCCI, age, and sex demonstrated that higher IADL scores were associated with reduced mortality risk, whereas higher aaCCI and female sex were associated with increased risk. Hazard ratios and confidence intervals are presented in Table 2 and Fig. 5 . Age was not significantly associated with survival. Table 1 Patients characteristics and study results. Abbreviations: CCI - Charlson Comorbidity Index, IADL - instrumental activities of daily living, ICU- intensive care unit, IQR-interquartile range, NRS-numerical rating scale, PS- performance status Number n, (%) Intervention Palliative Control Together 22 (32) 28 (40) 19 (28) 69 (100) Age median years (Min-Max) 74 (65–84) 77 (69–86) 69 (65–77) 74 (65–86) Men n, (%) 10 (45) 17 (61) 9 (47) 36 (52) Women n, (%) 12 (55) 11 (39) 10 (53) 33 (48) median IADL 8 6 NA p = 0.025 Karnofsky PS median 100 80 NA p = 0.001 Pain NRS median (Min-Max) 0 (0–6) 2. 5 (0–8) NA p = 1 median length of stay at ICU (days) 6.0 NA 6.0 p = 0.97 Complications after surgery gr. > 3 n (%) 12 (54%) NA 8 (42%) p = 0.40 median Overall survival (IQR) months 14.3 (6.0 to 26.46) 7.5 (2.96 to 15.6 ) 16.3 (8.5 to 25.6) P vs I, p = 0.054; I vs C, p = 0.63; P vs C, p = 0.058 C + I vs P, p = 0.02 adjuvant chemotherapy administartion n, (%) 6 (27%) NA 6 (31%) OR 0.812, p = 1.0 palliative chemotherapy administartion n, (%) 7 (32%) 9 (32%) 4 (21%) S vs C OR 1.75, p = 0.49 P vs C OR 1.77, p = 0.515 EORTC-QLQ-C30 Physical functioning average score 82.4 52.4 NA p = 0.028 EORTC-QLQ-C30 Fatigue average score 30.6 60.9 NA p = 0.042 Table 2 multiple univariate analysis by Mann-Whitney U test and Welch test with Bonferonni correction to test the difference between groups P and I in several parameters. The variable is considered significant if p_bonferroni < 0.05. numerical values of the CPH parameters. exp(coef) = HR. aaCCI - age adjusted Charlson Comorbidity Index, IADL - instrumental activities of daily living. IADL coef exp(coef) se(coef) coef lower 95% coef upper 95% exp(coef) lower 95% exp(coef) upper 95% -0.27 0.77 0.07 -0.41 -0.12 0.66 0.89 Age -0.01 0.99 0.03 -0.07 0.05 0.93 1.06 Sex 0.70 2.02 0.34 0.03 1.38 1.03 3.97 aaCCI 0.28 1.33 0.13 0.03 0.54 1.03 1.71 Discussion The present study evaluated the role of comprehensive palliative geriatric assessment in shared decision-making for older patients with resectable pancreatic ductal adenocarcinoma. Our findings suggest that structured collaboration between pancreatic surgeons and palliative care specialists may improve identification of geriatric patients who are suitable candidates for pancreatic surgery without worsening postoperative outcomes. Pancreatic resection followed by adjuvant chemotherapy remains the only potentially curative treatment for pancreatic adenocarcinoma; however, treatment decisions in older patients are challenging due to frailty, multimorbidity, and risk of functional decline [7, 8, 9]. Chronological age alone is insufficient for surgical selection, and inappropriate patient selection may lead to postoperative deterioration without meaningful survival benefit, while carefully selected older patients may achieve surgical outcomes comparable to younger patients [12, 13], especially when ERAS (Enhanced Recovery After Surgery) recommendations are followed [14]. Shared decision-making represents an essential component of contemporary person-centered oncology care [15]. It is a time-consuming process requiring communication skills that extend beyond usual surgical training and time constraints [16]. Palliative care specialists, trained in communication and goal-of-care discussions, may contribute substantially to this process by integrating medical risk assessment with patients' values, expectations, and functional status [15]. Patients and their families are ensured that their values and preferences truly matter and that the treatment plan is concordant with their goals of care. A shared decision-making process led by a palliative care specialist ensures that patients are not left to face difficult choices alone and will not be abandoned by clinicians if they decide not to proceed with surgery or other anticancer treatment [15]. Our model of early palliative involvement allowed individualized treatment decisions while maintaining comparable surgical morbidity and intensive care unit utilization between surgically treated groups, as reflected by comparable Clavien–Dindo complication rates (p = 0.40) and intensive care unit length of stay (p = 0.97). Although median overall survival did not differ significantly among study groups due to low number of subjects (P vs I p = 0.054; I vs C p = 0.63; P vs C p = 0.058), the significantly longer survival observed in surgically treated patients — 16.3 months in the combined intervention and control group compared to 7.5 months in the palliative group (C + I vs P p = 0.02) — suggests a potential benefit of careful patient selection. Importantly, only a minority of operated patients received adjuvant chemotherapy: 27% in the intervention group and 31% in the control group, with no statistically significant difference between them (p = 1.00). This highlights a clinical dilemma frequently encountered in geriatric pancreatic oncology — technical resectability does not necessarily translate into treatment tolerance [17]. The majority of operated patients did not receive adjuvant chemotherapy due to decline in performance status and increased geriatric frailty. The risk of adverse events following chemotherapy administration in geriatric patients can be estimated using the CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) score [18]. Among the evaluated parameters, age-adjusted Charlson Comorbidity Index (aaCCI) and Instrumental Activities of Daily Living (IADL) emerged as independent predictors of treatment allocation between the intervention and palliative groups in multivariate logistic regression analysis. Patients with lower comorbidity burden — median aaCCI 6 in the intervention group versus 7.5 in the palliative group (p = 0.016) — and preserved functional independence — median IADL 8 versus 6 (p = 0.025) — were more likely to be selected for surgery and demonstrated improved survival outcomes. Notably, chronological age was not significantly associated with survival in Cox proportional hazards modelling, further supporting the principle that functional status rather than age should guide treatment decisions in this population. A logistic model based solely on aaCCI showed limited predictive accuracy when applied to the control group (53%), underscoring that isolated comorbidity assessment is insufficient without comprehensive geriatric evaluation. Quality-of-life domains, specifically EORTC QLQ-C30 Physical Functioning (82.4 vs 52.4, p = 0.028) and Fatigue (30.6 vs 60.9, p = 0.042), significantly differed between the intervention and palliative groups and were associated with treatment allocation; however, they did not independently predict survival in multivariate analysis. The EORTC QLQ-C30 nonetheless represents an important validated tool for patient self-assessment and, in other studies, has provided independent prognostic information with potential implications for patient stratification in clinical trials [19, 20]. Our comprehensive palliative geriatric assessment identified 22 patients (32%) initially considered frail or borderline by surgeons who subsequently underwent surgery with postoperative outcomes — including complication rates and intensive care utilization — comparable to the 19 patients selected directly for surgical treatment in the control group. These findings suggest that structured palliative geriatric evaluation may prevent both undertreatment and overtreatment in older patients with resectable pancreatic cancer. Simple and reproducible tools such as IADL and aaCCI appear practical for routine clinical use and may effectively support shared decision-making in a busy surgical practice. This study has several limitations. These include a relatively small sample size, single-center design, retrospective data collection, absence of randomization, and incomplete functional and quality-of-life data in the control group. External validation in larger prospective cohorts is therefore required. Conclusion Comprehensive palliative geriatric assessment supports shared decision-making in older patients with resectable pancreatic ductal adenocarcinoma and can identify surgical candidates who might otherwise be excluded based on initial clinical impression alone. Among the parameters assessed, IADL and aaCCI were the most useful independent predictors of treatment allocation; however, a single-parameter model based on aaCCI alone was insufficient to capture the full complexity of geriatric evaluation, highlighting the need for a multidimensional approach. Differences in physical functioning and fatigue scores between the intervention and palliative groups reflect the clinical relevance of functional assessment in treatment planning and are consistent with evidence supporting early integration of palliative care in pancreatic cancer management. When surgery is not indicated, simultaneous planning of oncological and palliative treatment — addressing symptoms, prognosis, and individual patient priorities — is essential to ensure continuity and quality of care. Equally, surgical candidates benefit from optimal pre- and postoperative preparation within centers capable of providing integrated oncological and palliative expertise. Early integration of palliative geriatric assessment into the preoperative pathway represents a feasible and potentially beneficial strategy to optimize treatment selection in older patients with resectable pancreatic cancer. Future prospective studies with larger patient cohorts should aim to validate standardized multidisciplinary algorithms that combine surgical evaluation with geriatric and palliative care expertise, with the goal of improving both treatment appropriateness and patient-centered outcomes. Statements and Declarations The authors have no relevant financial or non-financial interest to disclose that are relevant to the content of this article. This research did not received any funding. All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of the National Cancer Institute in Bratislava, Slovakia. Author Contribution LD, AS designed the study. LD collected the data. JS statistically analysed the data. LD, JS wrote the main manuscript text, JS prepared statistics and Figures 2-5, LD prepared Fig 1. MM and KG contributed to study supervision and criticall revision of the manuscript. All authors reviewed and approved the final version of the manuscript. Acknowledgement We gratefully acknowledge the cooperation with surgeons, anesthesiologists, nurses and all other colleagues involved in the health care given to pancreatic cancer patients. We deeply appreciate the trust given us by our patients and their relatives during the treatment Data Availability All data supporting the findings of this study are available within the paper and its Supplementary Information. References Danpanichkul P, Pang Y, Tothanarungroj P, et al. Gastrointestinal cancer statistics in 2022 and projection to 2050: GLOBOCAN estimates across 185 countries. Cancer. 2026 [Epub ahead of print]. doi:10.1002/cncr.70245 Ludmir EB, Mainwaring W, Lin TA, et al. Factors associated with age disparities among cancer clinical trial participants. JAMA Oncol. 2019;5(12):1769-1773. Kolbeinsson HM, Chandana S, Wright GP, Chung M. Pancreatic cancer: a review of current treatment and novel therapies. J Invest Surg. 2023;36(1):2129884.. Hartog M, Beishuizen SJE, Togo R, et al. Comprehensive geriatric assessment, treatment decisions, and outcomes in older patients eligible for pancreatic surgery. J Surg Oncol. 2024;130(8):1643-1653. Cramer CL, Kane WJ, Lattimore CM, et al. Evaluating the impact of preoperative geriatric-specific variables and modified frailty index on postoperative outcomes after elective pancreatic surgery. World J Surg. 2022;46(11):2797-2805. Aregui A, Estrada J, Lefèvre M, et al. Geriatric assessment and management, prehabilitation and rehabilitation for older adults with non-colorectal digestive cancers. Cancers. 2025;17(9):1589. Ogden JR, Xie H, Ma WW, et al. The management of older adults with pancreatic adenocarcinoma. Geriatrics. 2018;3:85. Keniga J, Szabata K, Mitus J, et al. Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery. Eur J Surg Oncol. 2020;46:2091-2098. Scholer AJ, Marcus R, Garland-Kledzik M, et al. Validating biological age in selecting elderly patients with pancreatic cancer for surgical resection. J Surg Oncol. 2023;127:394-404 Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85:365-376. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213. Levi ST, Gough BL, Darcy CE, et al. Pancreatic resections: 30 and 90-day outcomes in octogenarians. Surg Oncol. 2021;37:101319. Mima K, Hayashi H, Nakagawa S, et al. Frailty is associated with poor prognosis after resection for pancreatic cancer. Int J Clin Oncol. 2021;26:1938-1946. Melloul E, Lassen K, Roulin D, et al. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg. 2020;44:2056-2084. Huang H. Shared decision-making with palliative care specialist. J Hosp Palliat Care. 2025;28:131-137. Dengsø KE, Berg A, Hensen CP, et al. Have a vital end-user been overlooked? Developing a shared decision intervention for patients with potential pancreatic cancer regarding the choice of surgery. PEC Innov. 2024;4:100269. Goede V. Frailty and cancer: current perspectives on assessment and monitoring. Clin Interv Aging. 2023;18:505-521.. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer . 2012;118(13):3377-3386. Gupta D, Lis CG, Grutsch JF. The European organization for research and treatment of cancer quality of life questionnaire: implications for prognosis in pancreatic cancer. Int J Gastrointest Cancer. 2006;37(2-3):65-73. Christiansen GG, Farnes I, Hjermstad MJ, Labori KJ. Association between baseline quality of life and survival in patients with non-metastatic, advanced pancreatic cancer. Scand J Gastroenterol. 2026;61(1):53-60. Additional Declarations No competing interests reported. Supplementary Files Supplement1.xlsx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 May, 2026 Reviews received at journal 14 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers invited by journal 09 Apr, 2026 Editor assigned by journal 09 Apr, 2026 Submission checks completed at journal 09 Apr, 2026 First submitted to journal 07 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9346804","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623429590,"identity":"9beb0f74-f0eb-4346-ba5f-358096401d64","order_by":0,"name":"Lucia Dzurillová","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBACPiA+wMDADKQYGw88AFL8EIkEnFrYkLQ0HACpk2wgQgsDRAtQL0idwQFCWiSSHx74wWBtb3D7MNCWisPyxrebj0kw/EnDoyXN4GAPQzqzwblEoJYzhw233TmWJsHYloNHSw7DAR6Gw2wGZ4B+SWxLY9x2I8dMgrGhAq+Wg38YDvPAtNhvngHUwvAHv5bDQFskoFpsEjdIgLSw4XEYzzODwzIG6QaSIC0JZ2ySZ9xIS7YAWodTCz978uOPbyqs7fnOsD988KFCwrZ/RvLBGx/+JOPUAgEG6AIJBDSMglEwCkbBKMAPAJgHVJR0GIZCAAAAAElFTkSuQmCC","orcid":"","institution":"National Cancer Institute, Bratislava, Slovakia","correspondingAuthor":true,"prefix":"","firstName":"Lucia","middleName":"","lastName":"Dzurillová","suffix":""},{"id":623429591,"identity":"cf2bb807-f9d5-42df-93ae-65dabab2a827","order_by":1,"name":"Andrea Škripeková","email":"","orcid":"","institution":"Slovak Medical University","correspondingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Škripeková","suffix":""},{"id":623429592,"identity":"5c18eef2-f51d-425e-927c-11d80d088e4a","order_by":2,"name":"Jan Smrek","email":"","orcid":"","institution":"University of Vienna","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"","lastName":"Smrek","suffix":""},{"id":623429593,"identity":"af13c6f6-bc16-48ef-9d8d-65305ea557f6","order_by":3,"name":"Katarína Gazdíková","email":"","orcid":"","institution":"Slovak Medical University","correspondingAuthor":false,"prefix":"","firstName":"Katarína","middleName":"","lastName":"Gazdíková","suffix":""},{"id":623429596,"identity":"3b45fc2a-a832-4f73-9f87-3b6542f15f54","order_by":4,"name":"Michal Mego","email":"","orcid":"","institution":"National Cancer Institute, Bratislava, Slovakia","correspondingAuthor":false,"prefix":"","firstName":"Michal","middleName":"","lastName":"Mego","suffix":""}],"badges":[],"createdAt":"2026-04-07 14:55:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9346804/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9346804/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107484665,"identity":"5392d0b0-bfbc-4e1e-b170-15ae5e448a5d","added_by":"auto","created_at":"2026-04-22 02:32:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98723,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/ce4e89469c3279ea7b7bb394.png"},{"id":107483403,"identity":"bb1a58ae-10a4-4e22-9de1-206443bc31b4","added_by":"auto","created_at":"2026-04-22 02:27:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":605916,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Maier curves of survival: mOS in palliative group was 7.5 months, mOS in intervention group was 14.3 months, mOS in Control group was 16.3 months, P vs I, p=0.054; I vs C, p=0.63; P vs C, p=0.058). Confidence interval of 95% is marked as dotted lines.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/39530cdf28bde5e1d5f60c48.png"},{"id":107256538,"identity":"066bc8f6-5b4e-4768-9540-3f66d04f7342","added_by":"auto","created_at":"2026-04-19 12:17:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":551369,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Maier curves of survival C+I vs P: mOS in combined C+I 16.3 months vs P mOS 7.5 months, \u0026nbsp;HR = 1.78, 95% CI 1.08–2.92, p = 0.02. Confidence interval of 95% is marked as dotted lines.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/0c23e916d481f3b6935d4e61.png"},{"id":107484656,"identity":"0d806cd2-f307-45b0-b1cd-4d3df846028e","added_by":"auto","created_at":"2026-04-22 02:32:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":571282,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplots of variables that differ significantly in (Mann-Whitney U test, p values shown) between the palliative (P) and the Intervention (I) groups.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/c9eba787cf9abe1ff619154a.png"},{"id":107256540,"identity":"dc4d1343-6ce6-4c0c-8300-1111eb35ba1d","added_by":"auto","created_at":"2026-04-19 12:17:33","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":29646,"visible":true,"origin":"","legend":"\u003cp\u003eCPH model. Logarithms of hazard ratio (HR) shown including 95% confidence intervals (CI). aaCCI - age adjusted Charlson Comorbidity Index, IADL - instrumental activities of daily living.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/37bb62826c3379078f2c7bdc.png"},{"id":109081031,"identity":"56521a58-b773-4465-9630-1f2e5bdb8ce7","added_by":"auto","created_at":"2026-05-12 11:53:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2086275,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/37593748-c8b6-4b65-9b0f-8a04b27debad.pdf"},{"id":107256537,"identity":"84110be3-4551-42a0-bff2-56574a2b7832","added_by":"auto","created_at":"2026-04-19 12:17:33","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":2859770,"visible":true,"origin":"","legend":"","description":"","filename":"Supplement1.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-9346804/v1/e5bda1eb3004f8011f9a92c6.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Palliative geriatric assessment in selection of older patients with resectable pancreatic ductal adenocarcinoma for surgical treatment","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePancreatic cancer accounted for 510,990 new cases worldwide in 2022 and its incidence is expected to rise to 998,660 by 2050 according to GLOBOCAN (Global Cancer Observatory) data [1]. Among gastrointestinal malignancies, pancreatic cancer shows one of the fastest rising trends in both incidence and mortality [1]. The median age at diagnosis is 71 years, reflecting the growing impact of pancreatic cancer in the aging population [1]. Despite this demographic reality, elderly patients remain underrepresented in clinical trials evaluating pancreatic cancer treatment, with the median age of enrolled patients reported to be approximately six years lower than that observed in the general population [2]. Consequently, evidence guiding treatment decisions in geriatric patients remains limited.\u003c/p\u003e \u003cp\u003ePancreatic surgery is a technically demanding procedure associated with postoperative complication rates approaching 30% and perioperative mortality 1\u0026ndash;3%, even in high-volume centers [3]. Current studies addressing treatment decision-making in older patients mainly focus on postoperative outcomes and survival after surgery. [4, 5, 6]. However, data describing treatment trajectories and outcomes of patients deemed unfit for surgical intervention remain scarce [4, 5, 6].\u003c/p\u003e \u003cp\u003eComprehensive geriatric assessment and other measures has been proposed as a tool to evaluate functional reserve, frailty, and treatment tolerance beyond chronological age [7, 8, 9]. Integration of palliative care principles into the preoperative evaluation may further support shared decision-making by incorporating patients\u0026rsquo; functional status, symptom burden, and individual goals of care. Nevertheless, the role of structured palliative geriatric assessment in selecting elderly patients with resectable pancreatic ductal adenocarcinoma for surgery has not been sufficiently explored.\u003c/p\u003e \u003cp\u003eThe aim of this study was to evaluate factors influencing shared decision-making in treatment allocation of older patients with resectable pancreatic ductal adenocarcinoma and to compare survival and treatment outcomes according to treatment strategy.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design and patients\u003c/h2\u003e \u003cp\u003eThis single-center study was conducted at the National Cancer Institute, Bratislava, Slovakia, between 2019 and 2024. The study included patients older than 65 years with newly diagnosed primary resectable pancreatic ductal adenocarcinoma (PDAC). Patients were initially evaluated by a pancreatic surgeon. Patients considered clearly fit were directly indicated for pancreatic surgery (control group, C). When surgical fitness was uncertain, patients were referred to an outpatient oncologic palliative care clinic for comprehensive palliative geriatric assessment.\u003c/p\u003e \u003cp\u003eThe study cohort consisted of 50 consecutive patients referred for palliative geriatric assessment prior to planned surgery and 19 patients who underwent surgery without such assessment (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Palliative geriatric assessment and intervention\u003c/h2\u003e \u003cp\u003eThe outpatient oncologic palliative care clinic provides early integrated palliative care for cancer patients at all disease stages. The assessment was performed by a palliative care physician who is also a medical oncologist. Comprehensive palliative geriatric assessment included: detailed medical history and symptom evaluation, physical examination, Instrumental Activities of Daily Living (IADL), age-adjusted Charlson Comorbidity Index (aaCCI), Karnofsky Performance Status (KPS), pain intensity assessed using Numeric Rating Scale, body mass index (BMI), echocardiography and pulmonary function examination, laboratory testing (liver enzymes, cholinesterase, bilirubin, albumin, CRP, CA19-9, creatinine). Patients completed quality-of-life questionnaires EORTC QLQ-C30 (version 3) and EORTC PAN26 at the initial assessment [10].\u003c/p\u003e \u003cp\u003eFollowing evaluation, a structured consultation with the patient and family members focused on disease understanding, treatment options, risks and benefits, symptom burden, and individual goals of care. Shared decision-making was used to determine the treatment strategy. Patients assessed as fit underwent pancreatic resection (intervention group, I). Patients considered unfit received oncologic treatment and specialist palliative care (palliative group, P).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Study outcomes and eligibility criteria\u003c/h2\u003e \u003cp\u003ePatients eligible for inclusion were aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years, had newly diagnosed resectable pancreatic ductal adenocarcinoma, were evaluated by a pancreatic surgeon at our institution, and provided informed consent for palliative geriatric assessment. Exclusion criteria included age\u0026thinsp;\u0026lt;\u0026thinsp;65 years, non-PDAC histology, borderline resectable or unresectable disease, and patient refusal of palliative geriatric assessment.\u003c/p\u003e \u003cp\u003eThe primary endpoint was overall survival among three groups of geriatric patients with resectable PDAC:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003epatients directly selected for surgery by surgeon (control group, C), (n\u0026thinsp;=\u0026thinsp;19),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003epatients assessed as fit for surgery after palliative geriatric assessment (intervention group, I), (n\u0026thinsp;=\u0026thinsp;22),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003epatients considered unfit or unwilling to undergo surgery and treated with palliative care (palliative group, P), (n\u0026thinsp;=\u0026thinsp;28).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eOverall survival was defined as time from date of diagnosis to death from any cause. Secondary endpoints included postoperative complications, administration of oncologic treatment, quality-of-life parameters, length of stay at intensive care unit (ICU), and rates of adjuvant or palliative chemotherapy. Postoperative complications were classified according to the Clavien\u0026ndash;Dindo classification [11].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data collection\u003c/h2\u003e \u003cp\u003eClinical data were obtained from the hospital information system of the National Cancer Institute. Collected variables included demographic characteristics, laboratory parameters (albumin, cholinesterase, CA19-9), functional status (IADL, aaCCI, quality of life questionnaires), surgical characteristics, postoperative complications, length of stay at ICU, administration of adjuvant or palliative chemotherapy and overall survival. Patients were followed from the date of diagnosis until death or 31st December 2024, whichever occurred first.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.4. \u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize baseline characteristics. Continuous variables were expressed as median and interquartile range (IQR), and categorical variables as absolute numbers and percentages. Each group was characterized by calculating proportional representation, median and interquartile range in each category. Overall survival was analysed using Kaplan\u0026ndash;Meier curves and compared between groups using the log-rank test. Due to moderate sample size, selected clinically relevant variables were prescreened using univariate analysis with Bonferroni correction for multiple testing. Variables reaching statistical significance were entered into multivariate logistic regression models to identify predictors of treatment allocation (P vs I groups). The observed follow-up time statistics was computed directly from all observed follow-up times, including the censored cases. The association between selected variables and survival was evaluated using multivariate Cox proportional hazards models. Statistical significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Baseline characteristics were calculated in the software Numbers version 6.1 (Apple) and statistical testing of groups differences using software Python 3.9.12 with modules scipy 1.11.1., scikit-survival 0.21.0, scikit-learn 1.2.2, statsmodels 0.13.2.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patients characteristics\u003c/h2\u003e \u003cp\u003eA total of 69 patients were included in the analysis: 36 men (53%), 33 women (47%). Median age was 69 (range 65\u0026ndash;77) years in Control group (C), 74 years (range 65\u0026ndash;84 years) in Intervention group (I) and 77 (range 69\u0026ndash;86 years) in Palliative group (P). Basic demographics characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Overall survival\u003c/h2\u003e \u003cp\u003eThe median follow-up times were 6.5 months (range 0.9\u0026ndash;52.6), 12.7 (range 0.9\u0026ndash;63.5) and 16.3 (range 1.1\u0026ndash;78.9) months for P, I and C groups respectively. Median overall survival (mOS) was 7.5 months (IQR 2.96 to 15.6 months) in palliative group, 14.3 months (IQR: 6.0 to 26.46 months) in intervention group, and 16.3 months (IQR: 8.5 to 25.6 months) in the control group. Kaplan-Meier curves of survival in groups I, P, C are in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Log-rank testing showed no statistical differences between groups (P vs I, HR\u0026thinsp;=\u0026thinsp;1.78, 95% CI 0.97\u0026ndash;3.27, p\u0026thinsp;=\u0026thinsp;0.054; I vs C, HR\u0026thinsp;=\u0026thinsp;0.85, 95%CI. 0.44\u0026ndash;1.64, p\u0026thinsp;=\u0026thinsp;0.63; P vs C, HR\u0026thinsp;=\u0026thinsp;1.72, 95%CI. 0.96\u0026ndash;3.09, p\u0026thinsp;=\u0026thinsp;0.058). When the C and I groups were combined and compared with the P group, the difference reached statistical significance: mOS C\u0026thinsp;+\u0026thinsp;I 16,3months (IQR: 7.3 to 26.5months) vs mOS P 7.5 months (IQR 2.96 to 15.6 months), HR\u0026thinsp;=\u0026thinsp;1.78, 95% CI 1.08\u0026ndash;2.92, p\u0026thinsp;=\u0026thinsp;0.02. Kaplan-Meier curves of survival in C\u0026thinsp;+\u0026thinsp;I vs P groups are in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Parameters associated with treatment allocation\u003c/h2\u003e \u003cp\u003eComparison between intervention and palliative groups demonstrated significant differences in several parameters obtained during palliative geriatric assessment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Significant variables included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eage-adjusted Charlson Comorbidity Index (aaCCI)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInstrumental Activities of Daily Living (IADL)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eKarnofsky Performace Status\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEORCT QLQ-C30 Physical Functionig\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEORTC QLQ-C30 Fatigue (All p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eMedian aaCCI was 6 in both I and C group vs 7.5 in P group (p\u0026thinsp;=\u0026thinsp;0.016), median IADL was 8 in I vs 6 in P group (p\u0026thinsp;=\u0026thinsp;0,025), median Karnofsky performance status was 100% in I group vs 80% in P group (p\u0026thinsp;=\u0026thinsp;0.001). We compared all functional and symptom scales and also global health status in quality of life questionnaires EORTC QLQ-C30. We found significant differences only in EORTC QLQ C30 Physical Functioning scale with higher average score in I group 82.4 vs P group 52.4 (p\u0026thinsp;=\u0026thinsp;0.028), and in the Fatigue scale with lower average score in I group 30.6 vs P group 60.9 (p\u0026thinsp;=\u0026thinsp;0.042).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Oncologic treatment\u003c/h2\u003e \u003cp\u003eAdjuvant chemotherapy administration did not differ between C and I group (Fisher\u0026rsquo;s exact test p\u0026thinsp;=\u0026thinsp;1.00), 6 (27%) patients in I group and 6 (31%) patients in C group received adjuvant chemotherapy,16 (73%) patients in intervention group and 13 (69%) patients in control group did not receive adjuvant chemotherapy due to decline in performance status. Palliative chemotherapy was administered in 9 patients (32%) in the palliative group, 7 patients (32%) in the intervention group, and 4 patients (21%) in the control group, without statistically significant differences (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Surgical outcomes\u003c/h2\u003e \u003cp\u003eLength of stay in the intensive care unit did not differ significantly between surgical groups (Mann\u0026ndash;Whitney U test p\u0026thinsp;=\u0026thinsp;0.97). The rate of postoperative complications classified according to Clavien\u0026ndash;Dindo was also comparable between groups (p\u0026thinsp;=\u0026thinsp;0.40).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Multivariate analysis\u003c/h2\u003e \u003cp\u003eMultivariate logistic regression models identified aaCCI and IADL as independent predictors of treatment allocation between intervention and palliative groups. Additional variables demonstrated collinearity and were excluded from final models. A logistic model based solely on aaCCI showed limited predictive performance when applied to the control group (classification accuracy 53%), suggesting that isolated comorbidity assessment is insufficient without comprehensive geriatric evaluation. Cox proportional hazards modelling including IADL, aaCCI, age, and sex demonstrated that higher IADL scores were associated with reduced mortality risk, whereas higher aaCCI and female sex were associated with increased risk. Hazard ratios and confidence intervals are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e. Age was not significantly associated with survival.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Patients characteristics and study results. Abbreviations: CCI - Charlson Comorbidity Index, IADL - instrumental activities of daily living, ICU- intensive care unit, IQR-interquartile range, NRS-numerical rating scale, PS- performance status\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber n, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePalliative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTogether\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (40)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (28)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e69 (100)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge median years\u003c/p\u003e \u003cp\u003e(Min-Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003cp\u003e(65\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003cp\u003e(69\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69\u003c/p\u003e \u003cp\u003e(65\u0026ndash;77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e74\u003c/p\u003e \u003cp\u003e(65\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMen n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWomen n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emedian IADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.025\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKarnofsky PS median\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain NRS median (Min-Max)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2. 5 (0\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emedian length of stay at ICU (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications after surgery gr. \u0026gt; 3 n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (54%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (42%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003emedian Overall survival (IQR) months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3 (6.0 to 26.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.5 (2.96 to 15.6 )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.3 (8.5 to 25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP vs I, p\u0026thinsp;=\u0026thinsp;0.054; I vs C, p\u0026thinsp;=\u0026thinsp;0.63; P vs C, p\u0026thinsp;=\u0026thinsp;0.058\u003c/p\u003e \u003cp\u003e\u003cb\u003eC\u0026thinsp;+\u0026thinsp;I vs P, p\u0026thinsp;=\u0026thinsp;0.02\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eadjuvant chemotherapy administartion n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (31%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR 0.812, p\u0026thinsp;=\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epalliative chemotherapy administartion n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (21%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eS vs C OR 1.75, p\u0026thinsp;=\u0026thinsp;0.49\u003c/p\u003e \u003cp\u003eP vs C OR 1.77, p\u0026thinsp;=\u0026thinsp;0.515\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEORTC-QLQ-C30 Physical functioning\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eaverage score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.028\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEORTC-QLQ-C30 Fatigue\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eaverage score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003ep\u0026thinsp;=\u0026thinsp;0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003emultiple univariate analysis by Mann-Whitney U test and Welch test with Bonferonni correction to test the difference between groups P and I in several parameters. The variable is considered significant if p_bonferroni\u0026thinsp;\u0026lt;\u0026thinsp;0.05. numerical values of the CPH parameters. exp(coef)\u0026thinsp;=\u0026thinsp;HR. aaCCI - age adjusted Charlson Comorbidity Index, IADL - instrumental activities of daily living.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIADL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecoef\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eexp(coef)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ese(coef)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecoef lower 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ecoef upper 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eexp(coef) lower 95%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eexp(coef) upper 95%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.27\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.41\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.12\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eaaCCI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study evaluated the role of comprehensive palliative geriatric assessment in shared decision-making for older patients with resectable pancreatic ductal adenocarcinoma. Our findings suggest that structured collaboration between pancreatic surgeons and palliative care specialists may improve identification of geriatric patients who are suitable candidates for pancreatic surgery without worsening postoperative outcomes.\u003c/p\u003e \u003cp\u003ePancreatic resection followed by adjuvant chemotherapy remains the only potentially curative treatment for pancreatic adenocarcinoma; however, treatment decisions in older patients are challenging due to frailty, multimorbidity, and risk of functional decline [7, 8, 9]. Chronological age alone is insufficient for surgical selection, and inappropriate patient selection may lead to postoperative deterioration without meaningful survival benefit, while carefully selected older patients may achieve surgical outcomes comparable to younger patients [12, 13], especially when ERAS (Enhanced Recovery After Surgery) recommendations are followed [14].\u003c/p\u003e \u003cp\u003eShared decision-making represents an essential component of contemporary person-centered oncology care [15]. It is a time-consuming process requiring communication skills that extend beyond usual surgical training and time constraints [16]. Palliative care specialists, trained in communication and goal-of-care discussions, may contribute substantially to this process by integrating medical risk assessment with patients' values, expectations, and functional status [15]. Patients and their families are ensured that their values and preferences truly matter and that the treatment plan is concordant with their goals of care. A shared decision-making process led by a palliative care specialist ensures that patients are not left to face difficult choices alone and will not be abandoned by clinicians if they decide not to proceed with surgery or other anticancer treatment [15].\u003c/p\u003e \u003cp\u003eOur model of early palliative involvement allowed individualized treatment decisions while maintaining comparable surgical morbidity and intensive care unit utilization between surgically treated groups, as reflected by comparable Clavien\u0026ndash;Dindo complication rates (p\u0026thinsp;=\u0026thinsp;0.40) and intensive care unit length of stay (p\u0026thinsp;=\u0026thinsp;0.97). Although median overall survival did not differ significantly among study groups due to low number of subjects (P vs I p\u0026thinsp;=\u0026thinsp;0.054; I vs C p\u0026thinsp;=\u0026thinsp;0.63; P vs C p\u0026thinsp;=\u0026thinsp;0.058), the significantly longer survival observed in surgically treated patients \u0026mdash; 16.3 months in the combined intervention and control group compared to 7.5 months in the palliative group (C\u0026thinsp;+\u0026thinsp;I vs P p\u0026thinsp;=\u0026thinsp;0.02) \u0026mdash; suggests a potential benefit of careful patient selection. Importantly, only a minority of operated patients received adjuvant chemotherapy: 27% in the intervention group and 31% in the control group, with no statistically significant difference between them (p\u0026thinsp;=\u0026thinsp;1.00). This highlights a clinical dilemma frequently encountered in geriatric pancreatic oncology \u0026mdash; technical resectability does not necessarily translate into treatment tolerance [17]. The majority of operated patients did not receive adjuvant chemotherapy due to decline in performance status and increased geriatric frailty. The risk of adverse events following chemotherapy administration in geriatric patients can be estimated using the CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) score [18].\u003c/p\u003e \u003cp\u003eAmong the evaluated parameters, age-adjusted Charlson Comorbidity Index (aaCCI) and Instrumental Activities of Daily Living (IADL) emerged as independent predictors of treatment allocation between the intervention and palliative groups in multivariate logistic regression analysis. Patients with lower comorbidity burden \u0026mdash; median aaCCI 6 in the intervention group versus 7.5 in the palliative group (p\u0026thinsp;=\u0026thinsp;0.016) \u0026mdash; and preserved functional independence \u0026mdash; median IADL 8 versus 6 (p\u0026thinsp;=\u0026thinsp;0.025) \u0026mdash; were more likely to be selected for surgery and demonstrated improved survival outcomes. Notably, chronological age was not significantly associated with survival in Cox proportional hazards modelling, further supporting the principle that functional status rather than age should guide treatment decisions in this population. A logistic model based solely on aaCCI showed limited predictive accuracy when applied to the control group (53%), underscoring that isolated comorbidity assessment is insufficient without comprehensive geriatric evaluation. Quality-of-life domains, specifically EORTC QLQ-C30 Physical Functioning (82.4 vs 52.4, p\u0026thinsp;=\u0026thinsp;0.028) and Fatigue (30.6 vs 60.9, p\u0026thinsp;=\u0026thinsp;0.042), significantly differed between the intervention and palliative groups and were associated with treatment allocation; however, they did not independently predict survival in multivariate analysis. The EORTC QLQ-C30 nonetheless represents an important validated tool for patient self-assessment and, in other studies, has provided independent prognostic information with potential implications for patient stratification in clinical trials [19, 20].\u003c/p\u003e \u003cp\u003eOur comprehensive palliative geriatric assessment identified 22 patients (32%) initially considered frail or borderline by surgeons who subsequently underwent surgery with postoperative outcomes \u0026mdash; including complication rates and intensive care utilization \u0026mdash; comparable to the 19 patients selected directly for surgical treatment in the control group. These findings suggest that structured palliative geriatric evaluation may prevent both undertreatment and overtreatment in older patients with resectable pancreatic cancer. Simple and reproducible tools such as IADL and aaCCI appear practical for routine clinical use and may effectively support shared decision-making in a busy surgical practice.\u003c/p\u003e \u003cp\u003eThis study has several limitations. These include a relatively small sample size, single-center design, retrospective data collection, absence of randomization, and incomplete functional and quality-of-life data in the control group. External validation in larger prospective cohorts is therefore required.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eComprehensive palliative geriatric assessment supports shared decision-making in older patients with resectable pancreatic ductal adenocarcinoma and can identify surgical candidates who might otherwise be excluded based on initial clinical impression alone. Among the parameters assessed, IADL and aaCCI were the most useful independent predictors of treatment allocation; however, a single-parameter model based on aaCCI alone was insufficient to capture the full complexity of geriatric evaluation, highlighting the need for a multidimensional approach.\u003c/p\u003e \u003cp\u003eDifferences in physical functioning and fatigue scores between the intervention and palliative groups reflect the clinical relevance of functional assessment in treatment planning and are consistent with evidence supporting early integration of palliative care in pancreatic cancer management. When surgery is not indicated, simultaneous planning of oncological and palliative treatment \u0026mdash; addressing symptoms, prognosis, and individual patient priorities \u0026mdash; is essential to ensure continuity and quality of care. Equally, surgical candidates benefit from optimal pre- and postoperative preparation within centers capable of providing integrated oncological and palliative expertise.\u003c/p\u003e \u003cp\u003eEarly integration of palliative geriatric assessment into the preoperative pathway represents a feasible and potentially beneficial strategy to optimize treatment selection in older patients with resectable pancreatic cancer. Future prospective studies with larger patient cohorts should aim to validate standardized multidisciplinary algorithms that combine surgical evaluation with geriatric and palliative care expertise, with the goal of improving both treatment appropriateness and patient-centered outcomes.\u003c/p\u003e "},{"header":"Statements and Declarations","content":" \u003cp\u003eThe authors have no relevant financial or non-financial interest to disclose that are relevant to the content of this article. This research did not received any funding.\u003c/p\u003e \u003cp\u003e All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Bioethics Committee of the National Cancer Institute in Bratislava, Slovakia.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eLD, AS designed the study. LD collected the data. JS statistically analysed the data. LD, JS wrote the main manuscript text, JS prepared statistics and Figures 2-5, LD prepared Fig 1. MM and KG contributed to study supervision and criticall revision of the manuscript. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe gratefully acknowledge the cooperation with surgeons, anesthesiologists, nurses and all other colleagues involved in the health care given to pancreatic cancer patients. We deeply appreciate the trust given us by our patients and their relatives during the treatment\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll data supporting the findings of this study are available within the paper and its Supplementary Information.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eDanpanichkul P, Pang Y, Tothanarungroj P, et al. Gastrointestinal cancer statistics in 2022 and projection to 2050: GLOBOCAN estimates across 185 countries. Cancer. 2026 [Epub ahead of print]. doi:10.1002/cncr.70245\u003c/li\u003e\n \u003cli\u003eLudmir EB, Mainwaring W, Lin TA, et al. Factors associated with age disparities among cancer clinical trial participants. JAMA Oncol. 2019;5(12):1769-1773.\u003c/li\u003e\n \u003cli\u003eKolbeinsson HM, Chandana S, Wright GP, Chung M. Pancreatic cancer: a review of current treatment and novel therapies. J Invest Surg. 2023;36(1):2129884..\u003c/li\u003e\n \u003cli\u003eHartog M, Beishuizen SJE, Togo R, et al. Comprehensive geriatric assessment, treatment decisions, and outcomes in older patients eligible for pancreatic surgery. J Surg Oncol. 2024;130(8):1643-1653.\u003c/li\u003e\n \u003cli\u003eCramer CL, Kane WJ, Lattimore CM, et al. Evaluating the impact of preoperative geriatric-specific variables and modified frailty index on postoperative outcomes after elective pancreatic surgery. World J Surg. 2022;46(11):2797-2805.\u003c/li\u003e\n \u003cli\u003eAregui A, Estrada J, Lef\u0026egrave;vre M, et al. Geriatric assessment and management, prehabilitation and rehabilitation for older adults with non-colorectal digestive cancers. Cancers. 2025;17(9):1589.\u003c/li\u003e\n \u003cli\u003eOgden JR, Xie H, Ma WW, et al. The management of older adults with pancreatic adenocarcinoma. Geriatrics. 2018;3:85.\u003c/li\u003e\n \u003cli\u003eKeniga J, Szabata K, Mitus J, et al. Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery. Eur J Surg Oncol. 2020;46:2091-2098.\u003c/li\u003e\n \u003cli\u003eScholer AJ, Marcus R, Garland-Kledzik M, et al. Validating biological age in selecting elderly patients with pancreatic cancer for surgical resection. J Surg Oncol. 2023;127:394-404\u003c/li\u003e\n \u003cli\u003eAaronson NK, Ahmedzai S, Bergman B, et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85:365-376.\u003c/li\u003e\n \u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205-213.\u003c/li\u003e\n \u003cli\u003eLevi ST, Gough BL, Darcy CE, et al. Pancreatic resections: 30 and 90-day outcomes in octogenarians. Surg Oncol. 2021;37:101319.\u003c/li\u003e\n \u003cli\u003eMima K, Hayashi H, Nakagawa S, et al. Frailty is associated with poor prognosis after resection for pancreatic cancer. Int J Clin Oncol. 2021;26:1938-1946.\u003c/li\u003e\n \u003cli\u003eMelloul E, Lassen K, Roulin D, et al. Guidelines for perioperative care for pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) recommendations 2019. World J Surg. 2020;44:2056-2084.\u003c/li\u003e\n \u003cli\u003eHuang H. Shared decision-making with palliative care specialist. J Hosp Palliat Care. 2025;28:131-137.\u003c/li\u003e\n \u003cli\u003eDengs\u0026oslash; KE, Berg A, Hensen CP, et al. Have a vital end-user been overlooked? Developing a shared decision intervention for patients with potential pancreatic cancer regarding the choice of surgery. PEC Innov. 2024;4:100269.\u003c/li\u003e\n \u003cli\u003eGoede V. Frailty and cancer: current perspectives on assessment and monitoring. Clin Interv Aging. 2023;18:505-521..\u003c/li\u003e\n \u003cli\u003eExtermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. \u003cem\u003eCancer\u003c/em\u003e. 2012;118(13):3377-3386.\u003c/li\u003e\n \u003cli\u003eGupta D, Lis CG, Grutsch JF. The European organization for research and treatment of cancer quality of life questionnaire: implications for prognosis in pancreatic cancer. Int J Gastrointest Cancer. 2006;37(2-3):65-73.\u003c/li\u003e\n \u003cli\u003eChristiansen GG, Farnes I, Hjermstad MJ, Labori KJ. Association between baseline quality of life and survival in patients with non-metastatic, advanced pancreatic cancer. Scand J Gastroenterol. 2026;61(1):53-60.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bratislava-medical-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Bratislava Medical Journal](https://link.springer.com/journal/44411)","snPcode":"44411","submissionUrl":"https://submission.springernature.com/new-submission/44411/3","title":"Bratislava Medical Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"pancreatic cancer, older patients, geriatric assessment, pancreatic surgery, frailty, decision-making","lastPublishedDoi":"10.21203/rs.3.rs-9346804/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9346804/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical treatment of older patients with resectable pancreatic ductal adenocarcinoma (PDAC) is limited by comorbidities, frailty, and risk of postoperative functional deterioration. The study aimed to evaluate factors influencing shared decision-making in treatment allocation of geriatric patients with resectable PDAC and to compare survival and postoperative outcomes according to treatment strategy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003ePatients older than 65 years with primary resectable PDAC were prospectively enrolled. Patients were either directly indicated for surgery by a surgeon or referred for comprehensive palliative geriatric assessment when surgical fitness was uncertain. Patients assessed as fit underwent pancreatic resection, whereas unfit patients received oncologic and palliative treatment. Clinical, functional, and quality-of-life parameters were analysed. Multivariate logistic regression included age-adjusted Charlson Comorbidity Index (aaCCI), Instrumental Activities of Daily Living (IADL), Karnofsky Performance Status (KPS), and selected EORTC QLQ-C30 variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSixty-nine patients were included; 19 directly selected for surgery (Control group- C), 22 assessed as fit after geriatric evaluation (Intervention group - I), and 28 assigned to palliative treatment (Palliative group- P). Median overall survival (mOS) did not significantly differ between groups (7.5 vs. 14.26 vs. 16.3 months; P vs I, p\u0026thinsp;=\u0026thinsp;0.054; I vs C, p\u0026thinsp;=\u0026thinsp;0.63; P vs C, p\u0026thinsp;=\u0026thinsp;0.058). When we compared mOS of all operated patients (C\u0026thinsp;+\u0026thinsp;I) versus palliative group, the difference reached statistical significance (16,3 months vs 7.5 monhts, HR\u0026thinsp;=\u0026thinsp;1.78, 95% CI 1.08\u0026ndash;2.92, p\u0026thinsp;=\u0026thinsp;0.02). Length of intensive care unit stay, severe postoperative complications, and chemotherapy administration were comparable. Significant differences between intervention and palliative groups were found in aaCCI (p\u0026thinsp;=\u0026thinsp;0.016), IADL (p\u0026thinsp;=\u0026thinsp;0.025), KPS (p\u0026thinsp;=\u0026thinsp;0.001), fatigue (p\u0026thinsp;=\u0026thinsp;0.042), and physical functioning (p\u0026thinsp;=\u0026thinsp;0.028). Multivariate analysis identified aaCCI and IADL as independent predictors of treatment allocation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eComprehensive palliative geriatric assessment supports shared decision-making and may help identify older patients suitable for pancreatic surgery despite initial concerns regarding frailty. aaCCI and IADL represent practical clinical parameters for surgical selection; further validation in larger cohorts is required.\u003c/p\u003e","manuscriptTitle":"Palliative geriatric assessment in selection of older patients with resectable pancreatic ductal adenocarcinoma for surgical treatment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 12:17:29","doi":"10.21203/rs.3.rs-9346804/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-04T06:42:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T21:35:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"251666375178126161702366067735817759036","date":"2026-04-14T21:24:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136749780641935404390768008606192928595","date":"2026-04-12T07:02:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-09T19:21:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T12:01:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-09T12:01:16+00:00","index":"","fulltext":""},{"type":"submitted","content":"Bratislava Medical Journal","date":"2026-04-07T14:38:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bratislava-medical-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Bratislava Medical Journal](https://link.springer.com/journal/44411)","snPcode":"44411","submissionUrl":"https://submission.springernature.com/new-submission/44411/3","title":"Bratislava Medical Journal","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"bba0270c-c903-4d03-9754-475d42fc3e58","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-04T06:42:57+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T07:39:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 12:17:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9346804","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9346804","identity":"rs-9346804","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}