The impact of age on postoperative functional decline and length of hospital stay in free flap reconstruction for head and neck cancer

Introduction

In Australia, head and neck cancer predominantly affects adults over the age of 65 years, with incidence steadily increasing with age (1). This trend, coupled with Australia’s ageing population, presents significant challenges in the decision-making and treatment of elderly patients with head and neck cancer. These challenges extend beyond clinical outcomes, affecting individual quality of life and placing broader demands on the healthcare system.

Elderly patients diagnosed with head and neck cancer are more likely than younger patients to have medical comorbidities and impaired functional status (2). Extensive surgical resection and free flap reconstruction is the standard curative option for many locoregionally advanced cases and a significant number of these patients will also require adjuvant chemoradiotherapy. Choosing to undertake such an intensive treatment course is a collaborative process, requiring open communication between patients and clinicians to align the patient’s fitness for surgery with their treatment priorities and goals of care.

Free flap reconstruction has been shown to be safe and effective in appropriately selected elderly patients, achieving good oncological and surgical outcomes (3-5). Beyond survival and disease control, maintaining independence and functional recovery are key priorities for elderly patients undergoing cancer treatment (6). From the patient’s perspective, these factors frequently outweigh life extension when evaluating treatment options (6).

Despite its importance to patients, there is limited information regarding functional outcomes for elderly patients following head and neck cancer resection and free flap reconstruction (7,8), and none in an Australian cohort. This study seeks to address this knowledge gap by evaluating the relationship between age and increased postoperative care requirements and length of hospital stay in patients undergoing this extensive surgery. The findings aim to inform preoperative counselling, enhance shared decision-making, and support the delivery of patient-centred care tailored to the values and priorities of elderly patients.

Methods

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was reviewed by the Chairperson of the Metro North Health Human Research Ethics Committee (project No. 112652) and deemed exempt from full ethical review on the basis that it is a quality initiative. Individual consent for this retrospective analysis was waived. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-25-11/rc).

In this retrospective study, we reviewed all adult patients who underwent free flap reconstruction for head and neck cancer at the Royal Brisbane and Women’s Hospital between January 2015 and December 2020. Patients were included if they underwent primary tumour resection and reconstruction following assessment by the Head and Neck Multidisciplinary Team (HNMDT). Resections were performed by the Ear, Nose and Throat or Plastic and Reconstructive Surgical (PRS) units, with all reconstructions carried out by the PRS unit. Cases involving osteoradionecrosis, trauma, infection, or revisionary procedures were excluded.

Elderly patients were defined as those aged ≥65 years, consistent with the Australian government definition (9), with an additional subgroup of patients ≥75 years to align with other studies (5,10). Patients were stratified by age into three groups: <65, 65–74, and ≥75 years. Data collected included demographics, length of hospital stay and surgical characteristics (operative duration, ablative site, reconstructive donor site and tracheostomy status). Ablative sites were categorised as “mucosal” for defects involving the oral cavity, oropharynx, larynx/hypopharynx and sinonasal subsites, or “cutaneous” for defects involving the skin of the face, neck, scalp or ear.

Baseline functional status was obtained from the admission Patient Risk Assessment (PRA) form in the electronic medical record (EMR) to assess the patient’s preoperative ability to carry out activities of daily living. If the PRA was incomplete, supplemental information was obtained from allied health notes, including physiotherapy, occupational therapy, and social work. Discharge functional status was obtained from the Community Interface Services note in the EMR. Baseline and discharge functional status were categorised as “Independent”, “Assisted” (e.g., living at home with a carer, living with family or receiving community care support), or “Nursing Home/Supported living facility”. Additional discharge categories included “Rehabilitation facility”, or “Deceased” if the patient died during the admission. Functional decline was defined as a change in functional status category at discharge to a greater level of assistance, excluding short-term wound care or drain management. Data was collected in Microsoft Excel (Microsoft, Redmond, WA, USA).

Descriptive statistics were presented as numbers and percentages for categorical variables. Continuous variables were assessed for normality with histograms and the Shapiro-Wilk test. Normally distributed variables were summarised with mean and standard deviation (SD) and non-normally distributed variables were summarised with median and interquartile range (IQR). Multiple logistic regression was used to determine the effect on functional decline of age group, ablative site and reconstruction method. Multiple linear regression was used to determine the effect on length of stay of age group, ablative site and reconstruction method. Odds ratios (OR) are presented with 95% confidence intervals (CI). Differences in baseline demographics between those with and without functional decline were assessed with Fisher’s exact test. P values <0.05 were considered significant from the outset. Stata IC v16 for Mac (StataCorp, College Drive, Texas, USA) was used for statistical analysis.

Results

A total of 200 patients were included in the study. Patient demographic and surgical details are summarised in Table 1. The cohort had a mean age of 64 years (± SD, 12 years) and had a male predominance (n=161, 80.50%) compared to females (n=39, 19.50%). Patients were stratified by age into three groups: <65 years (n=96, 48%), 65–74 years (n=65, 32.50%), and ≥75 years (n=39, 19.50%). Preoperatively, the majority of patients were independent at home (n=193, 96.50%). Functional decline was observed in 16.50% (n=33) of patients; half were discharged home with increased support and half were transferred to an inpatient rehabilitation facility. Older patients were more likely to experience functional decline, with 51.28% (n=20) of patients ≥75 and 100% (n=5) of patients ≥85 requiring increased care on discharge.

The distribution of ablative sites was relatively even, with 111 (55.50%) categorised as cutaneous and 89 (44.50%) as mucosal. The majority of mucosal ablations were for primary tumours of the oral cavity (n=51, 57.30%). The most common free flap used was the anterolateral thigh (ALT) flap (n=96, 48%), followed by the radial artery forearm flap (RAFF; n=57, 28.50%). Median hospital length of stay was significantly longer for patients with functional decline (19 days, IQR: 11–28 days) compared to those without functional decline [14 days (IQR: 9–21 days), P<0.001]. Operative times were similar across groups, with a median duration of 11 hours (IQR: 10–13 hours for no decline, IQR: 10–14 hours for decline).

Multiple logistic regression was performed to assess the impact of age group, ablative site and type of free flap on functional decline (Table 2). The model was statistically significant at predicting functional decline [n=184, likelihood ratio (LR) χ²(6)=46.46, P<0.001]. Patients in the 65–74 years age group (OR 5.19, 95% CI: 1.32–20.38, P=0.018) and those aged ≥75 years (OR 27.17, 95% CI: 6.84–107.90, P<0.001) were significantly more likely to experience functional decline than those in the <65 years age group. Neither ablative site nor type of free flap used was significantly associated with functional decline (P>0.05).

Linear regression was used to determine the impact of age, ablative site and type of free flap on length of stay (Table 3). The model statistically significantly predicted decline (n=200, F(8,191) =4.91, P<0.001). Among the variables examined, mucosal ablative site was associated with a 7.97-day increase in length of stay (95% CI: 4.04–11.90, P<0.001), and latissimus dorsi (LD) flaps with an 8.79-day increase (95% CI: 3.49–14.09, P=0.001).

Tracheostomy use was correlated with increased length of stay, an association that appears to be independent of primary malignancy site. For cutaneous malignancies, a tracheostomy was associated with a prolonged length of stay by 11 days (95% CI: 3–18, P=0.005). For mucosal primaries, tracheostomy was associated with a prolonged length of stay by 7 days (95% CI: 2–10, P=0.001) and laryngectomy by 25 days (95% CI: 16–33, P<0.001). However, only two of the 89 patients with mucosal malignancies did not require tracheostomy or laryngectomy, against which the comparisons are being drawn.

Discussion

There was a significant association between age and decline in functional status following free flap reconstruction for head and neck cancer at our institution. Compared with younger patients, the odds of functional decline were 5× greater for those aged 65–74 years and 27× greater for those aged >75 years, necessitating a period of inpatient rehabilitation or increased community services to facilitate discharge. These findings underscore the importance of tailored preoperative counselling for older patients, emphasizing the possibility of additional care needs postoperatively and giving the opportunity to address these needs pre-emptively.

Studies investigating discharge destinations following head and neck reconstruction consistently show that increasing age is significantly associated with discharge to a post-care facility rather than home (10-13). Hatcher et al. demonstrated that the odds of discharge to a nursing or rehabilitation facility increased by 1.06 with each additional year of age (11). This finding translated to a 5-fold increased odds for individuals over 70 years and a 13-fold increased odds for those over 80 years. However, these studies did not distinguish between patients discharged home with support services and those who maintained full independence, potentially underestimating the extent of true functional decline. In comparison, we considered discharge home with increased services as a marker of functional decline, as this is relevant to preoperative counselling and resource planning.

Few studies have looked at functional decline beyond the point of discharge, with mixed results. Weaver et al. and Parsemain et al. reported that while a higher proportion of patients aged >70 years required discharge to post-acute facilities, most eventually returned home (14,15). Conversely, Fancy et al. examined patients older than 80 years and found that 11% experienced functional decline to nursing home dependence at 90 days post-surgery (7). Further to this, Davis et al. showed that once older patients are placed in nursing home care, dependency persists at 1-year follow-up (8).

In our cohort, surgical factors such as ablative site, reconstructive donor site, and operative duration were not significantly associated with functional decline. This aligns with findings from most studies (10,13,16), although Fancy et al. reported higher rates of functional decline at 90 days for mucosal donor sites (7). The most comprehensive analysis of ablative and reconstructive donor sites by Sweeny et al. also found no significant association with discharge destination but noted that increasing age and operative durations exceeding 10 hours reduced the likelihood of discharge home (10). An unexpected finding in our study was the lower percentage of tracheostomy patients who experienced functional decline. This may reflect the selection of younger, fitter patients for mucosal free flap reconstruction requiring a tracheostomy in our unit. Due to the limited number of osseous free flaps in the dataset, we were unable to compare outcomes with soft tissue flaps, although others have found no difference in discharge destination or length of stay (10,15).

Patients who experienced functional decline had prolonged hospital stays. Our median length of stay aligns with other Australian studies (5,17), and prolonged stays were associated with tracheostomy or laryngectomy, mucosal ablative sites, and the use of LD flaps. The addition of a tracheostomy tube increased the length of stay for patients with cutaneous primaries by an average of 11 days compared with those without. We hypothesize that the extended hospital stay for these cutaneous tracheostomy patients, along with the mucosal ablative site cases, is due to the additional time required to establish oral intake or alternative enteral feeding and to achieve tracheostomy decannulation. The additional effect on length of stay of tracheostomy or laryngectomy within the mucosal ablative site group must be interpreted with caution due to the limited numbers who maintained their own airway perioperatively. The association between LD flaps and longer stays may reflect their use in cases involving larger resection sites, sacrifice of a functional muscle, or the prolonged management of high-drain outputs commonly associated with this donor site (18). Future studies with detailed tracking of postoperative milestones, such as tracheostomy decannulation and removal of nasogastric tubes and surgical drains, could provide more accurate insights into these associations.

The literature is divided on whether age predicts length of stay (12,15), however, increased length of stay was consistently associated with discharge to a post-acute care facility in multiple other studies (11,19). Identification of high-risk patients at diagnosis and initiating discharge planning early in their admission may help reduce length of stay and facilitate a faster return home. This is crucial not only for patient well-being and efficient health service planning but also to avoid delays in adjuvant treatments, which can impact oncological outcomes (20).

Our findings must be interpreted in the context of several limitations. As a retrospective analysis, it is subject to potential biases from incomplete or inconsistent data, particularly regarding postoperative functional status. While baseline functional data was well documented in the PRA form, postoperative functional outcomes were less consistently recorded. Without a standardised functional assessment tool, a decrease in independence at discharge serves as a surrogate marker for overall functional decline but cannot examine specific domains or long-term recovery trajectories. Furthermore, we were unable to examine or account for potential confounding factors included by other studies such as comorbidities, family support, rurality or socioeconomic status (12,16,19). Controlling for these variables in future research is essential to validate the associations suggested by this study.

Selection bias is another limitation, as only patients deemed fit for surgery through the HNMDT were included, excluding frailer individuals who were not offered surgery or declined it. Additionally, this study’s single-centre design and unique demographics, including a high prevalence of cutaneous malignancy (21), limit the generalizability of our findings to other populations and healthcare settings.

Future prospective studies should address these limitations by utilising validated pre- and postoperative functional assessments such as the Katz-15 score (22), with longer follow-up intervals. Developing a head and neck free flap reconstruction pre-procedure checklist, as suggested by Chandna et al., that includes family support and baseline activities of daily living, could aid in the early identification and assistance of at-risk patients presented through the HNMDT (16).

Conclusions

This study highlights an association between advanced age and functional decline in patients undergoing free flap reconstruction for head and neck cancer in an Australian cohort. Patients aged >65 years demonstrated a greater likelihood of discharge with additional services, underscoring the importance of preoperative counselling and early discharge planning. Specific surgical factors such as tracheostomy insertion, mucosal site reconstruction and flap type may influence hospital length of stay, but did not affect functional status at discharge. Future prospective, multi-centre studies with extended follow-up and standardized measures of pre- and postoperative functional outcomes are essential to better understand and address the care needs of older patients undergoing these complex procedures.

Acknowledgments

We wish to acknowledge the Ear, Nose and Throat and Plastics and Reconstructive Surgery departments of the Royal Brisbane and Women’s Hospital for their support of this project.

Part of this manuscript was presented at the Royal Australasian College of Surgeons Annual Scientific Congress in May 2022.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/ajo-25-11/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-25-11/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-25-11/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-25-11/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was reviewed by the Chairperson of the Metro North Health Human Research Ethics Committee (project No. 112652) and deemed exempt from full ethical review on the basis that it is a quality initiative. Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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