Federal Practitioner

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

Chronic myeloid leukemia (CML) is a hematologic malignancy resulting from an acquired mutation. The mutation results in a reciprocal translocation between the long arms of chromosomes 9 and 22 and is known as the Philadelphia chromosome (Ph), or Ph-positive (Ph+) when present. The translocation results in the formation of a BCR-ABL fusion oncogene, which leads to continuous cell cycling and proliferation, altered differentiation, and a loss of apoptosis.^1,2

Until the 1980s, CML was considered fatal.³ The mainstay of treatment consisted of 2 oral chemotherapeutic agents, busulfan and hydroxyurea. These medications did not prevent blast crisis, a fatal form of leukemia.^4,5 The introduction of tyrosine kinase inhibitors (TKIs) transformed CML management and improved 10-year overall survival from about 20% to > 80% by delaying the transition to blast crisis. Now, the risk of death from general health conditions or comorbidities is higher than that of CML.⁶

TKIs target the root cause of CML through inhibition of the BCR-ABL oncoprotein.^1,2 For CML, the goals of treatment include maintaining hematologic, cytogenetic, and molecular remission; preventing progression to accelerated phase or blast crisis; minimizing toxicity; and enabling potential cessation of therapy in carefully selected patients.^7,8

Small cohort studies suggest that dose reduction of TKIs in patients who achieve optimal responses may reduce the risk of long-term adverse effects (AEs). However, optimal dose-reduction and minimum effective dose of each agent are unknown.⁷ The ability to maintain undetectable minimal residual disease or disease detectable at a stable low level after TKI discontinuation has been called treatment-free remission. Studies suggest that about 40% to 50% of patients who have achieved a stable deep molecular response remain in treatment-free remission after stopping first-line treatment.^9,10 Of the patients who relapse following TKI discontinuation, 80% relapse within the first 6 months of treatment cessation. Molecular response is regained in almost all patients when treatment is resumed with the same TKI.¹¹

The National Comprehensive Cancer Network (NCCN) recommends considering discontinuation of TKI therapy only outside the setting of a clinical trial and only in patients who consent to discontinuation after a thorough discussion of the potential risks and benefits. The NCCN criteria for patients who may be eligible for discontinuation are listed in Table 1. The Life After Stopping TKIs study reported that 80% of patients with well-controlled chronic phase CML who discontinued TKIs had a clinically meaningful improvement in fatigue. Patients also reported clinically meaningful improvements in depression, diarrhea, sleep disturbance, and pain interference. These symptoms worsened after restarting TKI therapy.¹²

TKI DISCONTINUATION

Electronic health record data were extracted using structured query language from the US Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). To be eligible for discontinuation, veterans had to be aged > 18 years, receive oncology care within a Veterans Integrated Services Network (VISN) 21 health care system (HCS) (VA Sierra Nevada HCS, VA Southern Nevada HCS, VA Central California HCS, VA Palo Alto HCS, VA Northern California HCS, and VA San Francisco HCS) or be a veteran referred to a community-based oncology practitioner. Patients had to have a documented diagnosis of chronic phase CML, have an active order for a TKI, be on TKI therapy for ≥ 3 years, and have a stable molecular response (BCR-ABL1 ≤ 0.01% on the International Scale for ≥ 2 years with ≥ 4 tests done ≥ 3 months apart) as of October 1, 2024. Veterans were excluded if they had a history of advanced accelerated phase CML, previous TKI discontinuation trials, nonadherence to the TKI, or if they did not want to consider TKI discontinuation.

This analysis evaluated the potential cost avoidance associated with TKI discontinuation. Cost avoidance was calculated using the average wholesale price of each TKI. Secondary objectives evaluated health outcomes of TKI discontinuation including CML relapse, reported AEs, long-term remission, and TKI withdrawal syndrome. Health outcomes were determined through chart review of AEs and clinic notes documented in the electronic health record during the study time frame.

Baseline information for eligible patients was collected, including age, sex, and race, and chart reviews were completed to evaluate reported AEs associated with therapy. Oncology clinical pharmacy practitioners (CPPs) at each VISN 21 facility were notified of eligible patients to facilitate discussion with oncologists and establish monitoring if therapy was discontinued. Following TKI discontinuation, health outcomes were evaluated, including CML relapse, changes in reported AEs, long-term remission, and TKI withdrawal syndrome. Descriptive statistics were used to analyze the baseline characteristics. Cost avoidance was calculated using the average wholesale price for each TKI. The number of tablets required to reach each patient’s individual dose was taken into consideration when determining the cost avoidance. A dashboard was created using the query from the CDW and was developed in Microsoft Power BI.

Preliminary Results

In FY 2024, VISN 21 had 3819 oncology patients. Twenty-four patients had taken a TKI for ≥ 3 years, 20 had a stable molecular response, and 15 had not previously attempted to discontinue their TKI (Figure 1). Fifteen veterans were eligible for therapy discontinuation for a total potential annual cost avoidance of $1.2 million (Figure 2). Most of the cost avoidance, $935,057 (78%), was attributed to 3 patients on nilotinib. The mean age of the population was 74 years. All patients were male, and 12 (80%) were White. (Table 2). At baseline, 11 patients (73%) were taking imatinib. One patient received oncology care from a community care clinician. All 15 patients decided to remain on therapy.

DISCUSSION

As a multisite quality improvement initiative, this project raised awareness of TKI therapy discontinuation in select patients with CML. It also sparked collaboration among oncology CPPs and clinicians and stimulated conversations about CML treatment. The development of the TKI discontinuation dashboard provides a population health management tool for CPPs and clinicians to identify eligible patients in the future.

Adherence to TKIs is crucial for disease control and survival in patients with CML. Patients are counseled that poor adherence to therapy may contribute to worsening disease or suboptimal response, the development of resistance, and greater health care costs.¹³ Therefore, it was a challenge for patients to understand and accept that they could stop TKI therapy after achieving a stable deep molecular response. Discussions with patients about the goal of therapy—suppressing the BCR-ABL oncogene, which they have achieved—could encourage patients to trial therapy discontinuation.

Only small cohort studies have been completed to evaluate the outcomes of therapy discontinuation. Much remains unknown regarding the optimal dose-reduction strategy and the minimum effective dose of each agent. Additionally, understanding the qualities of a good candidate for TKI discontinuation remains a barrier. A similar project was conducted in VISN 17. Five patients were counseled on TKI discontinuation; however, only 1 discontinued TKI therapy. Unfortunately, soon after discontinuing treatment, the patient had to restart therapy. Additional literature will enhance understanding of therapy discontinuation.

An unexpected finding of TKI discontinuation trials has been a reversible phenomenon known as TKI withdrawal syndrome.⁹ It can occur regardless of the TKI used and results in pruritus and new or worsening musculoskeletal pain within several weeks of TKI discontinuation in about 30% of patients. Symptoms may last several months and may require acetaminophen or nonsteroidal anti-inflammatory drugs for pain control.^9,10,14

The potential cost avoidance of $1.2 million is an underestimation because VA contracts allow for greater cost savings. However, that information is confidential and therefore average wholesale price had to be used for this project. Most of the cost avoidance was due to 4 patients who could not tolerate imatinib and used nilotinib, which is more expensive.

Limitations

The small sample size presented some limitations. Of the 3819 oncology patients within VISN 21 in FY 2024, 186 received a TKI and only 15 were eligible for discontinuation. Additionally, challenges emerged when discussing discontinuation with community care clinicians and patients. Community care clinicians were difficult to contact, making it challenging to discuss the project with them. CPPs noted hesitancy among VA clinicians and patients to discontinue a medication for which adherence was continually emphasized.

Conclusions

Discussions about CML TKI discontinuation led to collaboration with the oncology care team and could lead to significant cost avoidance. Barriers to TKI discontinuation included patients’ concern for relapse, risk of discontinuation syndrome, the requirement for close monitoring, and clinician buy-in. Outcome studies are needed to gain a greater understanding of the benefits and risks of therapy discontinuation. In the future, evaluation of possible clinical and biological predictors of successful TKI discontinuation may be beneficial.

The US Department of Veterans Affairs (VA) has adopted new technology designed to make it easier and faster for veterans to schedule appointments with community care health care practitioners (HCPs).

Through the External Provider Scheduling (EPS) system, VA employees can access the scheduling systems of participating community care HCPs. As of March 2026, 27,000 community care HCPs were participating in EPS across 78 medical specialties.

Without this system, VA employees have to call multiple community care HCPs and relay that information back to veterans before booking an appointment. As a result, a single VA employee could only schedule a handful of community care appointments per day, and it could take days or even weeks to book an appointment for a veteran.

Now, the new system—implemented in all VA facilities starting in late 2025—enables VA employees to schedule as many as 25 appointments daily.

“We are making it easier and more convenient than ever for those who have worn the uniform to choose the care that best fits their lifestyle,” VA Secretary Doug Collins said in a news release.

The VA goal is to sign up thousands of additional community care HCPs in 2026 as part of its continuing efforts to deliver timely, veteran-centered care. There is no cost for institutions to participate in the program.

Select Medical, an outpatient rehabilitation organization with > 1900 centers in 39 states and the District of Columbia, became aware of this opportunity in the first half of 2025: “At that time, we met with key VA stakeholders to learn more about the new program, the challenges it would address, and how it worked to evaluate our ability to participate,” said Chad Smith, president of the company’s outpatient division, headquartered in Mechanicsburg, Pennsylvania.

“We immediately saw the value in what the VA was seeking to accomplish and wanted to be part of providing increased access to exceptional care for our nation’s veterans,” Smith said.

In July 2025, Smith noted, Select Medical piloted the program in 2 states. After successful deployment, the organization broadened its participation to 15 states, offering “seamless access to care” to > 3000 veterans. They receive outpatient rehabilitative care, including physical and occupational therapy.

“The External Provider Scheduling system creates a more streamlined way for veterans and VA administrators to manage the appointment process,” Smith said.

Northwell Health in Lake Success, New York, expressed interest in the program last summer when approached by the VA and “jumped at it,” said Juan Serrano, MBA, MS, vice president of military liaison services at Northwell Health.

The Long Island-based system, which already had a long-standing relationship with the VA, rolled out the program to give veterans the ability to see community care HCPs, Serrano said.

The program started in November, with the first appointment booked in December. From then until the end of April, the program booked 69 appointments for almost 80 veterans, with gastroenterology and otolaryngology representing the highest volume specialties.

Veterans also have gained entry to several other specialty clinics, including imaging services. The program has decreased waiting times for veterans’ appointments and helped them establish rapport with community care HCPs, Serrano said.

“One of the biggest setbacks and difficulties veterans experience is timely access to care outside of the VA,” he said, adding, “as an organization, we made a pledge to create a pathway for veterans to complement the work of the VA and give veterans access to our network.”

The US Department of Veterans Affairs (VA) has adopted new technology designed to make it easier and faster for veterans to schedule appointments with community care health care practitioners (HCPs).

Through the External Provider Scheduling (EPS) system, VA employees can access the scheduling systems of participating community care HCPs. As of March 2026, 27,000 community care HCPs were participating in EPS across 78 medical specialties.

Without this system, VA employees have to call multiple community care HCPs and relay that information back to veterans before booking an appointment. As a result, a single VA employee could only schedule a handful of community care appointments per day, and it could take days or even weeks to book an appointment for a veteran.

Now, the new system—implemented in all VA facilities starting in late 2025—enables VA employees to schedule as many as 25 appointments daily.

“We are making it easier and more convenient than ever for those who have worn the uniform to choose the care that best fits their lifestyle,” VA Secretary Doug Collins said in a news release.

The VA goal is to sign up thousands of additional community care HCPs in 2026 as part of its continuing efforts to deliver timely, veteran-centered care. There is no cost for institutions to participate in the program.

Select Medical, an outpatient rehabilitation organization with > 1900 centers in 39 states and the District of Columbia, became aware of this opportunity in the first half of 2025: “At that time, we met with key VA stakeholders to learn more about the new program, the challenges it would address, and how it worked to evaluate our ability to participate,” said Chad Smith, president of the company’s outpatient division, headquartered in Mechanicsburg, Pennsylvania.

“We immediately saw the value in what the VA was seeking to accomplish and wanted to be part of providing increased access to exceptional care for our nation’s veterans,” Smith said.

In July 2025, Smith noted, Select Medical piloted the program in 2 states. After successful deployment, the organization broadened its participation to 15 states, offering “seamless access to care” to > 3000 veterans. They receive outpatient rehabilitative care, including physical and occupational therapy.

“The External Provider Scheduling system creates a more streamlined way for veterans and VA administrators to manage the appointment process,” Smith said.

Northwell Health in Lake Success, New York, expressed interest in the program last summer when approached by the VA and “jumped at it,” said Juan Serrano, MBA, MS, vice president of military liaison services at Northwell Health.

The Long Island-based system, which already had a long-standing relationship with the VA, rolled out the program to give veterans the ability to see community care HCPs, Serrano said.

The program started in November, with the first appointment booked in December. From then until the end of April, the program booked 69 appointments for almost 80 veterans, with gastroenterology and otolaryngology representing the highest volume specialties.

Veterans also have gained entry to several other specialty clinics, including imaging services. The program has decreased waiting times for veterans’ appointments and helped them establish rapport with community care HCPs, Serrano said.

“One of the biggest setbacks and difficulties veterans experience is timely access to care outside of the VA,” he said, adding, “as an organization, we made a pledge to create a pathway for veterans to complement the work of the VA and give veterans access to our network.”

The US Department of Veterans Affairs (VA) has adopted new technology designed to make it easier and faster for veterans to schedule appointments with community care health care practitioners (HCPs).

Through the External Provider Scheduling (EPS) system, VA employees can access the scheduling systems of participating community care HCPs. As of March 2026, 27,000 community care HCPs were participating in EPS across 78 medical specialties.

Without this system, VA employees have to call multiple community care HCPs and relay that information back to veterans before booking an appointment. As a result, a single VA employee could only schedule a handful of community care appointments per day, and it could take days or even weeks to book an appointment for a veteran.

Now, the new system—implemented in all VA facilities starting in late 2025—enables VA employees to schedule as many as 25 appointments daily.

“We are making it easier and more convenient than ever for those who have worn the uniform to choose the care that best fits their lifestyle,” VA Secretary Doug Collins said in a news release.

The VA goal is to sign up thousands of additional community care HCPs in 2026 as part of its continuing efforts to deliver timely, veteran-centered care. There is no cost for institutions to participate in the program.

Select Medical, an outpatient rehabilitation organization with > 1900 centers in 39 states and the District of Columbia, became aware of this opportunity in the first half of 2025: “At that time, we met with key VA stakeholders to learn more about the new program, the challenges it would address, and how it worked to evaluate our ability to participate,” said Chad Smith, president of the company’s outpatient division, headquartered in Mechanicsburg, Pennsylvania.

“We immediately saw the value in what the VA was seeking to accomplish and wanted to be part of providing increased access to exceptional care for our nation’s veterans,” Smith said.

In July 2025, Smith noted, Select Medical piloted the program in 2 states. After successful deployment, the organization broadened its participation to 15 states, offering “seamless access to care” to > 3000 veterans. They receive outpatient rehabilitative care, including physical and occupational therapy.

“The External Provider Scheduling system creates a more streamlined way for veterans and VA administrators to manage the appointment process,” Smith said.

Northwell Health in Lake Success, New York, expressed interest in the program last summer when approached by the VA and “jumped at it,” said Juan Serrano, MBA, MS, vice president of military liaison services at Northwell Health.

The Long Island-based system, which already had a long-standing relationship with the VA, rolled out the program to give veterans the ability to see community care HCPs, Serrano said.

The program started in November, with the first appointment booked in December. From then until the end of April, the program booked 69 appointments for almost 80 veterans, with gastroenterology and otolaryngology representing the highest volume specialties.

Veterans also have gained entry to several other specialty clinics, including imaging services. The program has decreased waiting times for veterans’ appointments and helped them establish rapport with community care HCPs, Serrano said.

“One of the biggest setbacks and difficulties veterans experience is timely access to care outside of the VA,” he said, adding, “as an organization, we made a pledge to create a pathway for veterans to complement the work of the VA and give veterans access to our network.”

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

More than 40 million surgeries are performed annually in the United States, of which > 18 million are orthopedic, including > 1 million emergency orthopedic surgeries and > 2 million joint replacements.^1-4 Notably, > 50% of patients undergoing orthopedic surgery are aged ≥ 65 years, a demographic shift driven by longer life expectancies and an increasing number of older adults remaining physically active for extended periods.⁵ Osteoarthritis, the most common joint disease, affects 10% of men and 18% of women aged > 60 years, often necessitating an orthopedic joint replacement.⁶ Perioperative morbidity and mortality are 2.9- to 6.7-times higher in older adults compared with younger adults.⁷ These risks include infection, venous thromboembolism (VTE), pressure ulcers, reduced mobility, and increased mortality. Due to the high incidence of these complications in older surgical patients, special perioperative protocols and considerations are needed when preparing an older patient for surgery. This review aims to establish concrete considerations and guidelines for perioperative management.

METHODOLOGY

A literature review of PubMed, Google Scholar, and IEEE Xplore identified research on perioperative challenges in geriatric orthopedic surgery. Keywords included geriatrics and orthopedic surgery, perioperative care in geriatric populations, and orthopedic perioperative care. Inclusion criteria were strictly defined to ensure relevance to the geriatric population, with studies focusing on patients aged ≥ 65 years. Exclusion criteria were applied to remove studies that did not involve geriatric populations or orthopedic surgeries or that lacked a clear perioperative focus. Studies were analyzed for design, interventions, and outcomes. Special attention was given to identifying common challenges and trends related to perioperative considerations. We developed a narrative report providing a comprehensive overview of the current understanding of perioperative care for geriatric orthopedic patients to offer practical recommendations for clinicians to use in their practice.

RESULTS

Consistent with the narrative review methodology described, the literature search yielded a broad range of publications addressing perioperative considerations in geriatric orthopedic patients. Articles were screened for relevance to patients aged ≥ 65 years undergoing orthopedic surgery and for applicability to perioperative optimization and postoperative outcomes. Given the heterogeneity in study design, population characteristics, and outcome reporting, findings are presented descriptively rather than being quantitatively pooled. Studies not focused on geriatric populations, orthopedic procedures, or perioperative management were excluded. Key themes included multimorbidity and comorbidity optimization, age-related physiologic changes, frailty assessment and fracture risk stratification, nutritional and bone health management, mechanism of injury considerations, prevention of postoperative complications, and the role of multidisciplinary perioperative care.

Unique Physiological Challenges

The aging process induces a range of physiological changes that can increase morbidity and mortality following surgery. One of the most essential elements to surgical recovery is wound healing, as impairments in this process can lead to adverse events, including infection, cosmetic deformity, and wound dehiscence. The general paradigm of aging involves cell senescence resulting in slower or disorganized functional capacity of these cells.⁸ While wound healing in older individuals was once thought to be defective, recent research has demonstrated that this process is not absent, but delayed.⁹

Wound healing is a tightly regulated and evolutionarily conserved process that proceeds through 3 main phases: inflammation, proliferation, and remodeling. Re-epithelialization begins with the migration of epithelial cells from hair follicles, sweat glands, or wound margins (depending on wound depth) and is influenced by oxygen levels, moisture, and growth factors.⁹ Several characteristics of aged skin contribute to the delayed healing process. Aged skin has fewer hair follicles and eccrine sweat glands, as well as decreased follicle thickness.¹⁰ This results in fewer proliferating cells for wound healing and lower amounts of sebum production for skin moisture.¹¹ Furthermore, aged fibroblasts are fewer in number and less effective in synthesizing extracellular matrices, resulting in slower and less tensile wound healing.¹² Additionally, microvascular changes associated with aging result in disorganized vasculature, which impairs oxygen delivery to the wound bed and diminishes the influx of proinflammatory cells necessary for effective healing.¹³ These senescent traits of aged skin contribute to the delayed wound healing process found in geriatric patients. 

Compounding these age-related factors is the prevalence of multimorbidity, or coexisting chronic diagnoses, in 55% to 98% of older patients.¹⁴ Common comorbidities include peripheral arterial disease, chronic venous insufficiency, type 1 and type 2 diabetes, neoplasms, atherosclerotic disease, and hypertension. Older patients are more likely to be prescribed corticosteroids and chemotherapeutic agents that impair the function of inflammatory cells necessary for wound healing.^15,16 Additionally, decreased mobility is more common in geriatric patients, which can increase the risk of wound formation, particularly pressure ulcers.¹⁷

Perioperative Considerations

All surgical patients undergo a formal or informal preoperative evaluation to assess their fitness for surgery, with the goal of minimizing both anesthesia-related risks and postoperative complications. A widely used tool in this assessment is the American Society of Anesthesiologists (ASA) physical status classification, which stratifies patients into 6 categories based on their medical history and overall health status.¹⁸ Classes range from healthy patients (Class I) to organ donors who are brain-dead (Class VI).

Cardiac optimization is an essential component of preoperative evaluation for older adults due to their higher risk of underlying cardiovascular disease.¹⁹ This process involves an in-depth review of the patient’s cardiac history, including the timing and nature of any prior interventions and the recurrence rate. Functional capacity is assessed through metabolic equivalents, where a threshold of > 4 metabolic equivalents (the ability to walk up a flight of stairs) is considered adequate for surgery. Risk is assessed based on the specific surgical procedure, and nonemergent orthopedic procedures are considered intermediate risk. If a patient is deemed high risk at any stage of this evaluation, further cardiac testing is indicated. 

Pulmonary optimization is typically necessary for geriatric patients, who are more likely to have conditions such as chronic obstructive pulmonary disease or interstitial lung disease.^14,20 In patients without severe systemic lung disease, pulmonary optimization involves assessing the functional expiratory volume and diffusing capacity for carbon monoxide. In addition, aggressive modification of risk factors, such as smoking cessation, is strongly recommended. 

Additional perioperative conditions are disease-specific and involve evaluation of comorbid illnesses and recognition of absolute contraindications to noncardiac surgery. For instance, an ejection fraction of < 35%, a history of myocardial infarction within 6 months, or active diabetic ketoacidosis are all absolute contraindications to elective surgery. For orthopedic procedures, additional contraindications include symptomatic bacteremia, active joint or local tissue infection, severe malnutrition, uncontrolled metabolic syndrome or chronic disease, untreated immunodeficiency, and active deep venous thrombosis (DVT) or pulmonary embolism.²¹

Bone Health and Nutrition

In the context of orthopedic surgery, the hallmark of clinically defined optimal bone health is a musculoskeletal system that provides the ability for pain-free functional and occupational tasks with an adequate capacity to withstand the mechanical forces imparted by everyday life. Back pain and arthritis are the fourth- and sixth-most common complaints in primary care, underscoring suboptimal bone health management in developed countries.²²

Optimizing bone health through proper nutrition is crucial in the perioperative management of geriatric orthopedic patients. The clinical diagnosis of malnutrition has well-studied associations with worse outcomes after orthopedic surgery, which include increased mortality, hospital length of stay, readmission rates, and health institution spending.^23-25 Some studies show that up to 60% of geriatric patients may be malnourished.²⁶ 

Regarding vitamin and mineral supplements, the general consensus before orthopedic surgery is that vitamins A, C, D, and E, and zinc are predictive in determining postoperative health.²⁷ However, Curtis et al state that therapy should be targeted at correcting relative deficiencies; supraphysiologic concentrations of these vitamins do not appear to be helpful.²⁷ This claim may merit serum studies to rule out deficiencies. Dietitians should be involved in the creation of a patient care plan in the spirit of multidisciplinary orthopedic surgery approaches, which have proven to result in superior patient outcomes.²⁸ Additionally, directive counseling should be provided when necessary. 

In patients with adequately managed nutrition, 7 to 10 days of diet optimization is typically sufficient, but patients with malnutrition may require sustained nutritional support for up to 6 weeks; a standardized time for adequate nutrition supplementation has not been identified.^25-27 Postoperative management is similar in older patients who are malnourished and those receiving adequate nutrition after orthopedic surgery, which typically involves 3 weeks of a high-protein diet.²⁶

Evaluating Mechanisms of Injury

Assessing the mechanism of injury (MOI) is essential to developing an appropriate and successful orthopedic treatment plan. MOI is typically categorized as low energy, which consists of ground-level falls and other minor trauma, or high energy, which can include motor vehicle crashes or falls from a height.²⁹ Unlike younger patients who typically experience trauma from high-energy MOIs, geriatric patients often sustain fractures from low-energy MOIs. The importance of assessing MOI for the geriatric population is magnified as it provides vital clues that not only help determine the nature of the injury, but also highlight underlying frailty, comorbidities, and potential complications. Weakness or deconditioning related to older age is often not discovered before trauma, which is why assessing the MOI can provide valuable information regarding overall patient health.³⁰

The MOI of trauma also is correlated with factors that influence postoperative recovery and overall prognosis (Figure). Falls comprise more than three-quarters of the MOI in geriatric patients with trauma, and > 90% of these falls are ground-level or other simple falls.³⁰ Falls secondary to an intrinsic disorder, rather than an extrinsic environmental hazard, are more common in geriatric patients.³¹ 

These events may be associated with an underlying medical condition, such as osteopenia, osteoporosis, or neuromuscular disorders, such as Parkinson disease.³² They may also be attributed to normal age-related changes, such as decreased visual acuity, reduced reaction time, or mild cognitive impairment.³⁰ An estimated 6% to 35% of geriatric patients who present to the emergency department have some degree of cognitive dysfunction.³³ Accordingly, a thorough understanding of the events leading up to injury is vital for the management of older patients. Knowing the specific circumstances of a fall can provide insight into the patient’s gait, balance, and need for further investigations such as cognitive screening or evaluation of home safety. This information can guide decisions regarding preoperative optimization of medications and postoperative rehabilitation interventions.

Frailty and Risk of Fracture

Frailty is a clinical syndrome defined by overall decreased capacity for the body’s adaptive changes to various stressors.³⁴ It is a common condition in geriatric populations due to cumulative degenerative changes and multisystem decline over a lifetime’s worth of disruptions to natural homeostasis.³⁴ In orthopedics, frailty typically refers to musculoskeletal durability and resilience in response to mechanical forces (ie, falls, trauma, and high-acceleration movements). Globally, > 200 million people have osteoporotic frailty, leading to 9 million hip fractures annually.³⁵ More than 30% of people aged ≥ 65 years fall ≥ 1 time per calendar year.³⁶

Assessing frailty in geriatric patients undergoing orthopedic surgery is vital, as it predisposes patients to higher rates of morbidity, mortality, and institutionalization, particularly from falls and resultant fragility fractures.^37-39 This is true for a wide range of orthopedic procedures, spanning elective to urgent surgeries and involving the axial and appendicular skeleton.^40,41 Given the high rates of fractures, subsequent patient morbidity, and financial burden on the health care system, effective frailty screening is essential. 

There are many strategies to assess frailty risk and subsequent fracture risk.⁴² Questionnaires or online medical calculators serve as easy-to-use tools for assessment of frailty or associated predictors of fragility fractures. Validated assessment tools are provided in Table 1. 

Dual-emission X-ray absorptiometry is a well-established way to determine bone density and establish fracture risk. The Fried Frailty Phenotype score and Short Performance Physical Battery test are clinically applicable methods of assessing frailty in older outpatient populations. Although these examinations focus on different aspects of the patient, they have moderate agreeability, are sensitive, and can be readily performed in the clinical setting as demonstrated by a > 90% patient participation rate for both methods.⁴² Finally, several serum studies can be predictive of frailty, the most readily modifiable of which are vitamin D3, ferritin, albumin, and calcium.⁴³ Although they are more invasive for the patient, serum studies can provide additional modifiable targets for perioperative optimization and contribute to risk stratification. 

Risk stratification should take place around 6 weeks before surgery, which should provide adequate time for rectification of preoperative barriers to elective surgical intervention—namely nutritional status. In cases of urgent or emergent procedures (ie, femoral neck fracture with concern for avascular necrosis of the femoral head), this may not be possible but should be conducted nonetheless for patient-specific postoperative rehabilitation and risk reduction.

Postoperative Complication Risks

Postoperative complications affect nearly 15% of geriatric orthopedic patients, highlighting the need for comprehensive preoperative evaluations to assess risk factors.⁴⁴ Age-related physiological changes, frailty, and comorbidities complicate recovery and management (Table 2).

Wound healing is impaired in older individuals due to suboptimal circulation and decreased oxygenation that is secondary to age-related changes, as well as the increased likelihood of comorbid conditions (eg, diabetes).⁷ Surgical site infections can be particularly malicious in geriatric patients, with a 4% incidence.^45,46 Hospitalization can be prolonged by a mean 2 weeks, which increases the risk of hospital-associated delirium and iatrogenic complications.⁴⁶ Both the mortality rate and costs associated with hospitalization are higher for older patients who develop surgical site infections compared with patients aged < 65 years, underscoring the importance of vigilant monitoring, early detection, and effective preoperative screening to identify and manage modifiable risk factors.⁴⁷ 

Postoperative delirium is another common complication of orthopedic surgery in the geriatric population, increasing morbidity and mortality. The incidence is reported to be as high as 53.3% in the trauma setting and 28.3% in the elective setting, indicating a need to assess patient risk preoperatively.^48,49 Several factors contribute to the high incidence of delirium, including advanced age, longer surgical durations, intraoperative hypotension and hypercapnia, pre-existing cognitive dysfunction, and postoperative sleep disorders.⁵⁰ 

VTE is another common cause of complications following orthopedic surgery. The development of DVT can lead to subsequent pulmonary embolism, which can be fatal. Orthopedic surgery patients are already at higher risk of DVT and VTE than other surgical patients, with an incidence as high as 40% to 60%, though it is frequently asymptomatic.^51,52 Geriatric patients may be more likely to have concurrent comorbidities that increase hypercoagulability.⁵³ Congestive heart failure, chronic kidney disease, and cardiovascular disease are all more common in older individuals and can increase the risk of VTE by 2-fold.⁵³ While anticoagulation is the standard of care to prevent VTE after orthopedic surgery, geriatric patients require more careful monitoring due to the higher incidence of bleeding complications. Additionally, early postoperative mobilization is critical to reduce the risk of DVT without significantly increasing pain or causing other adverse events.⁵⁴ 

Respiratory complications are common after orthopedic surgery, particularly atelectasis and bronchospasm, which can result from intraoperative mechanical ventilation.⁵⁵ While these conditions are typically self-limiting, more severe respiratory issues such as pneumonia are a significant concern because they may lead to the need for mechanical ventilation and admission to the intensive care unit (ICU). The more severe complications have an incidence of about 1% to 2% in orthopedic surgery patients.⁵⁶ Preventive strategies, such as respiratory physiotherapy and guided breathing exercises, are crucial to minimize perioperative pulmonary complications and promote optimal recovery. Addressing these challenges through early intervention is essential to improve outcomes.

Multidisciplinary Perioperative Care

Multidisciplinary care in orthopedic surgery involves collaborative management of patient care by general practitioners, surgeons, anesthesiologists, dietitians, physical and occupational therapists, inpatient health care practitioners (HCPs), and social services. The goal of this form of care is to provide a longitudinal sequence of health-optimization tactics that prepare a patient for surgery and give them the best chance of postoperative recovery.

Given that many aspects of geriatric health play a role in orthopedic postoperative outcomes, there are many preoperative factors to consider. As previously discussed, preoperative evaluation of geriatric patients should include nutritional and fragility screening to determine surgical candidacy and target modifiable risk factors for risk reduction. This screening can be conducted by primary care practitioners and orthopedic surgeons in an outpatient setting. A multidisciplinary approach benefits patients by decreasing time to surgery.³⁵ 

Several large studies have demonstrated the positive influence of a multidisciplinary approach on patient-oriented outcomes in orthopedic patients. Incorporation of this style of care in contrast to surgeon-led perioperative optimization leads to fewer floor and ICU admissions, shorter lengths of stay, and decreased mortality rates.^35,57 These findings are broadly applicable to a wide range of orthopedic surgeries and even surgeries outside of the musculoskeletal system.^58,59 In addition, this strategy has demonstrated reduced in-hospital health care costs due to shorter lengths of stay and fewer ICU admissions. Physical and occupational therapy also have irreplaceable roles in outcomes after orthopedic surgeries. They have independently been shown to decrease pain, increase range of motion, and increase functionality in daily life.⁶⁰ These aspects of recovery are essential for geriatric well-being.

Screening Tools

The World Health Organization FRAX fracture risk assessment tool (www.fraxplus.org/calculation-tool) was developed to identify patients at high risk of fracture and subsequent complications and to guide clinical decision-making regarding pharmacologic interventions.⁶¹ FRAX calculates the 10-year probability of fracture based on demographic factors, such as age and body mass index, clinical measures (eg, femoral neck bone mineral density), and risk factors (eg, prior fragility fractures, substance use history, and prolonged glucocorticoid use).⁶¹ The online tool is easy to use, making it a valuable resource for assessing fracture risk and determining appropriate treatment strategies.

The fatigue, resistance, ambulation, illnesses, loss of weight (FRAIL) scale assesses frailty in older adults. The scale classifies patients into 3 categories: robust, prefrail, and frail. The frail category is associated with an increased frequency of hip fracture and an elevated ASA class.⁶² Additionally, the FRAIL scale has demonstrated value in predicting hospital length of stay and the risk of postoperative complications.⁶² It also has shown utility in quantifying frailty status, which is traditionally challenging to assess systematically.⁶³

The Mini-Cog is commonly used in geriatric populations to screen for cognitive impairment. Preoperative Mini-Cog screening has been shown to predict the development of postoperative complications.⁶⁴ Geriatric patients who screened positive for cognitive impairment prior to orthopedic surgery were more likely to develop postoperative delirium, require alternative discharge disposition, and have a longer hospital length of stay.⁶⁴ Mini-Cog serves as an important preoperative tool for identifying patients who may benefit from closer postoperative monitoring and tailored care.

The Comprehensive Geriatric Assessment (CGA) is a multidimensional evaluation that has been validated for use in geriatric patients undergoing orthopedic surgery.⁶⁵ The CGA assesses functional status and the ability to perform activities of daily living (ADLs), such as eating, dressing, and ambulating. Poor ADLs are associated with increased risk of falls and cardiopulmonary complications. The CGA allows HCPs to identify patients at higher risk of complications and tailor interventions that optimize functional recovery during the perioperative period.

Nutritional screening is another component of preoperative evaluation in older adults undergoing orthopedic surgery. The Perioperative Nutrition Screen is a preoperative phone assessment of unintentional weight loss in the past 6 months.⁶⁶ Patients who screen positive are asked to come in for a preoperative visit with a registered dietitian who can further evaluate the nutritional status of the patient. 

The Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool, and Nutrition Risk Screening 2002 have all been validated for use in older patients undergoing orthopedic surgery. Among these, the MNA-SF has demonstrated superior utility in predicting hospital readmission and mortality.⁶⁷ Given the established links between malnutrition and poor surgical outcomes, routine nutritional screening is important for identifying geriatric patients who may require preoperative nutritional interventions.

CONCLUSIONS AND RECOMMENDATIONS

Perioperative management of geriatric patients undergoing orthopedic surgery requires an assessment and strategy focused on risk stratification, patient optimization, and mitigation of potential complications and mortality. Due to the complexity and comprehensive nature of an optimal perioperative plan, creating the plan early is essential to ensure adequate time for patient optimization and care coordination.

Nutrition plays a critical role in the success of surgical procedures, and orthopedics is no exception. Extra care should be taken to preoperatively optimize patient bone health before surgical intervention to enhance recovery and reduce the risk of complications. After an appropriate patient history and clinical picture are gathered, screening tools should be used on a case-by-case basis to further characterize comorbid conditions that may contribute to suboptimal outcomes. Additionally, given the proven association between frailty and fracture risk, frailty serves as a readily quantifiable predictor of patient-oriented outcomes. This should be assessed preoperatively with appropriate risk-stratification tools to determine appropriate postoperative measures to prevent morbidity and mortality. 

Orthopedic surgery is increasingly common in geriatric patients, who face higher perioperative risks due to age-related physiological changes, multimorbidity, and frailty. Optimizing preoperative assessment and adopting a multidisciplinary approach—integrating surgeons, anesthesiologists, physical therapists, and dietitians—can improve outcomes, reduce complications, and enhance recovery. The successful use of the tools and strategies outlined in this article by primary care should facilitate access to and recovery from orthopedic surgery in the geriatric population.

TOPLINE:

Among women aged > 65 years who were at a high risk for cervical cancer and required screening, only 5.2% received appropriate screening. Women with a history of high-grade cervical dysplasia had a greater likelihood of appropriate screening.

METHODOLOGY:

• Researchers conducted a retrospective study to assess the rates of appropriate cervical cancer screening among 1787 women aged 66 years or older (median, 76 years; 96.3% White) who had a Medicare wellness visit or an annual gynecologic visit in a healthcare system in 2022.
• Data on age at the last cervical cancer screening, history of hysterectomy, human papillomavirus (HPV) status, and history of a diagnosis of cervical cancer or cervical dysplasia, high-grade dysplasia, and immune deficiency status were assessed.
• Participants were categorized into 2 groups: those at high risk for cervical cancer (prior high-grade cervical dysplasia or cancer, an immunocompromised status, or lack of two normal cytology results in the past 10 years; n = 250) and those at average risk (having no high-risk features and adequate prior screening or having a prior hysterectomy with no history of high-grade cervical dysplasia; n = 1537).
• The screening cessation criteria were based on adequate prior screening, defined as two prior negative cervical cancer screenings in the past 10 years, the absence of high-grade cervical dysplasia or cervical cancer, and no immune deficiency.

TAKEAWAY:

• Overall, 4.9% of patients had a history of inadequate prior screening; among women at high risk, 5.2% were appropriately screened.
• The odds of continued screening were greater for women with a history of a positive HPV test results (adjusted odds ratio [aOR], 3.4; P = .016), a history of high-grade cervical dysplasia (aOR, 3.8; P = .009), and those without prior hysterectomy (aOR, 2.2; P = .005).
• Among women at high risk for cervical cancer, those with a history of high-grade cervical dysplasia had increased odds of appropriate screening (aOR, 6.7; P = .002), whereas the odds decreased with every 5-year increase in age (aOR, 0.5; P = .031). Women with prior hysterectomy were less likely to be over-screened (aOR, 0.3; P < .001) than those without.
• Among the 79 women who underwent screening, 97.5% had normal cytology results; the remaining women had abnormal cytology results (atypical squamous cells of undetermined significance or atypical squamous cells); all patients with abnormal cytology results met high-risk criteria and were screened appropriately.

IN PRACTICE:

“[The study] findings suggest that most clinicians and patients are aware of recommendations to stop cervical cancer screening after age 65 years. However, there may be a lack of awareness regarding continued screening in high-risk patients or those with inadequate prior screening. The lack of prior screening history and results in the medical record suggests that providers may not understand the importance of these factors to inform cervical cancer screening in older patients,” the authors of the study wrote.

SOURCE:

The study was led by Daniel Rodriguez, BS, Kolschowsky Research and Education Institute, Sarasota Memorial Health Care System, Sarasota, Florida. It was published online on April 23, 2026, in the Journal of Lower Genital Tract Disease.

LIMITATIONS:

Screening history in electronic medical records may be incomplete.

DISCLOSURES:

The Sarasota Memorial Healthcare Foundation provided financial support for this research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among women aged > 65 years who were at a high risk for cervical cancer and required screening, only 5.2% received appropriate screening. Women with a history of high-grade cervical dysplasia had a greater likelihood of appropriate screening.

METHODOLOGY:

• Researchers conducted a retrospective study to assess the rates of appropriate cervical cancer screening among 1787 women aged 66 years or older (median, 76 years; 96.3% White) who had a Medicare wellness visit or an annual gynecologic visit in a healthcare system in 2022.
• Data on age at the last cervical cancer screening, history of hysterectomy, human papillomavirus (HPV) status, and history of a diagnosis of cervical cancer or cervical dysplasia, high-grade dysplasia, and immune deficiency status were assessed.
• Participants were categorized into 2 groups: those at high risk for cervical cancer (prior high-grade cervical dysplasia or cancer, an immunocompromised status, or lack of two normal cytology results in the past 10 years; n = 250) and those at average risk (having no high-risk features and adequate prior screening or having a prior hysterectomy with no history of high-grade cervical dysplasia; n = 1537).
• The screening cessation criteria were based on adequate prior screening, defined as two prior negative cervical cancer screenings in the past 10 years, the absence of high-grade cervical dysplasia or cervical cancer, and no immune deficiency.

TAKEAWAY:

• Overall, 4.9% of patients had a history of inadequate prior screening; among women at high risk, 5.2% were appropriately screened.
• The odds of continued screening were greater for women with a history of a positive HPV test results (adjusted odds ratio [aOR], 3.4; P = .016), a history of high-grade cervical dysplasia (aOR, 3.8; P = .009), and those without prior hysterectomy (aOR, 2.2; P = .005).
• Among women at high risk for cervical cancer, those with a history of high-grade cervical dysplasia had increased odds of appropriate screening (aOR, 6.7; P = .002), whereas the odds decreased with every 5-year increase in age (aOR, 0.5; P = .031). Women with prior hysterectomy were less likely to be over-screened (aOR, 0.3; P < .001) than those without.
• Among the 79 women who underwent screening, 97.5% had normal cytology results; the remaining women had abnormal cytology results (atypical squamous cells of undetermined significance or atypical squamous cells); all patients with abnormal cytology results met high-risk criteria and were screened appropriately.

IN PRACTICE:

“[The study] findings suggest that most clinicians and patients are aware of recommendations to stop cervical cancer screening after age 65 years. However, there may be a lack of awareness regarding continued screening in high-risk patients or those with inadequate prior screening. The lack of prior screening history and results in the medical record suggests that providers may not understand the importance of these factors to inform cervical cancer screening in older patients,” the authors of the study wrote.

SOURCE:

The study was led by Daniel Rodriguez, BS, Kolschowsky Research and Education Institute, Sarasota Memorial Health Care System, Sarasota, Florida. It was published online on April 23, 2026, in the Journal of Lower Genital Tract Disease.

LIMITATIONS:

Screening history in electronic medical records may be incomplete.

DISCLOSURES:

The Sarasota Memorial Healthcare Foundation provided financial support for this research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

TOPLINE:

Among women aged > 65 years who were at a high risk for cervical cancer and required screening, only 5.2% received appropriate screening. Women with a history of high-grade cervical dysplasia had a greater likelihood of appropriate screening.

METHODOLOGY:

• Researchers conducted a retrospective study to assess the rates of appropriate cervical cancer screening among 1787 women aged 66 years or older (median, 76 years; 96.3% White) who had a Medicare wellness visit or an annual gynecologic visit in a healthcare system in 2022.
• Data on age at the last cervical cancer screening, history of hysterectomy, human papillomavirus (HPV) status, and history of a diagnosis of cervical cancer or cervical dysplasia, high-grade dysplasia, and immune deficiency status were assessed.
• Participants were categorized into 2 groups: those at high risk for cervical cancer (prior high-grade cervical dysplasia or cancer, an immunocompromised status, or lack of two normal cytology results in the past 10 years; n = 250) and those at average risk (having no high-risk features and adequate prior screening or having a prior hysterectomy with no history of high-grade cervical dysplasia; n = 1537).
• The screening cessation criteria were based on adequate prior screening, defined as two prior negative cervical cancer screenings in the past 10 years, the absence of high-grade cervical dysplasia or cervical cancer, and no immune deficiency.

TAKEAWAY:

• Overall, 4.9% of patients had a history of inadequate prior screening; among women at high risk, 5.2% were appropriately screened.
• The odds of continued screening were greater for women with a history of a positive HPV test results (adjusted odds ratio [aOR], 3.4; P = .016), a history of high-grade cervical dysplasia (aOR, 3.8; P = .009), and those without prior hysterectomy (aOR, 2.2; P = .005).
• Among women at high risk for cervical cancer, those with a history of high-grade cervical dysplasia had increased odds of appropriate screening (aOR, 6.7; P = .002), whereas the odds decreased with every 5-year increase in age (aOR, 0.5; P = .031). Women with prior hysterectomy were less likely to be over-screened (aOR, 0.3; P < .001) than those without.
• Among the 79 women who underwent screening, 97.5% had normal cytology results; the remaining women had abnormal cytology results (atypical squamous cells of undetermined significance or atypical squamous cells); all patients with abnormal cytology results met high-risk criteria and were screened appropriately.

IN PRACTICE:

“[The study] findings suggest that most clinicians and patients are aware of recommendations to stop cervical cancer screening after age 65 years. However, there may be a lack of awareness regarding continued screening in high-risk patients or those with inadequate prior screening. The lack of prior screening history and results in the medical record suggests that providers may not understand the importance of these factors to inform cervical cancer screening in older patients,” the authors of the study wrote.

SOURCE:

The study was led by Daniel Rodriguez, BS, Kolschowsky Research and Education Institute, Sarasota Memorial Health Care System, Sarasota, Florida. It was published online on April 23, 2026, in the Journal of Lower Genital Tract Disease.

LIMITATIONS:

Screening history in electronic medical records may be incomplete.

DISCLOSURES:

The Sarasota Memorial Healthcare Foundation provided financial support for this research. The authors declared having no conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article first appeared on Medscape.com.

Women who undergo surgery for breast cancer often hear that they should take it easy with exercise during recovery. But new research looking at intense strength training puts that advice into question.

The study, of nearly 200 women who’d undergone lumpectomy or mastectomy, found that a 3-month weight-training program helped patients make substantial gains in strength, mobility, balance, and body composition.

And while previous studies have examined resistance exercise during breast cancer surgery recovery, this program pumped up the intensity: Most women progressed to deadlifting 100 to 200 pounds, even though few had ever performed strength training before.

“Most of these patients can do a lot more than we think,” said principal investigator Colin Champ, MD, director of the Exercise Oncology and Resiliency Center at Allegheny Health Network in Pittsburgh.

The findings were presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, held in Seattle from April 29 to May 3.

Pumping Up the Intensity

For the analysis, Champ and his colleagues pooled the results of 3 small prospective studies of their strength conditioning program, including one that previously reported no worsening in patients’ lymphedema, and instead, showed signs of improvement.

The researchers evaluated program participants’ physical and functional gains and whether any of those parameters differed by the extent of their breast cancer surgery.

In total, there were 197 participants, including 85 who’d undergone mastectomies and 112 who’d had lumpectomies; 26 patients also had axillary lymph node dissection.

All of the women attended the same 3-month supervised strength-training program, starting at various points in their recovery process. Nearly half started at 3 months postdiagnosis.

According to Champ, the program addresses a full range of motion, with the exercise intensity building over a short period — similar to what professional athletes do in early training. The specific exercises include split squats, dumbbell presses, and dumbbell rows, done 3 days per week, for about 45-60 minutes.

Most participants, Champ said, start with deadlifting around 70 pounds (lifting weight from the floor to hip level). “If you can carry groceries, you can deadlift 60 or 70 pounds,” he noted.

Each month, the weight and sets increase, while the repetitions decrease.

“We just had a woman in her 70s who deadlifted about 200 pounds” as the program progressed, Champ said.

Benefits Regardless of Surgery Type

Women in the current analysis underwent baseline and post-program testing of body composition and functional parameters, including strength, mobility, and balance. Mastectomy patients (median age, 51 years) were younger than lumpectomy patients (median age, 59 years). They were also more likely to have had chemotherapy (45% vs 27%).

Overall, Champ’s team found that both surgery groups showed statistically significant improvements in muscle and body fat percentages over the course of the program, with muscle mass increasing by 1 percentage point on average and body fat declining by 1.5 percentage points.

Similarly, functional movement scores, grip strength, loads lifted, and balance skills also improved, with comparable benefits regardless of surgery type or whether lymph node dissection was performed.

By the end of the program’s third week, Champ said, most women could deadlift 100-pound weights. And by the 3-month mark, many were able to lift 200-pound loads.

Champ called the results empowering, and he hopes they help reframe the traditional mindset that intense strength training is too heavy a lift after breast cancer surgery.

A surgical oncologist who was not involved in the study agreed.

“This gives us something concrete to say to patients,” said Tina Hieken, MD, of the Mayo Clinic in Rochester, Minnesota. “We have more data to say it’s safe for you to exercise.’’

Hieken, who chaired the meeting’s scientific program committee, also noted that the findings pertain to women of all baseline fitness levels.

For her part, Hieken already encourages patients to walk for exercise and spend time outdoors — in part for the mental well-being benefits.

With patients facing so much uncertainty after a cancer diagnosis, she said, “this is something an individual can take control of.”

Champ and Hieken had no disclosures.

A version of this article first appeared on Medscape.com.

Women who undergo surgery for breast cancer often hear that they should take it easy with exercise during recovery. But new research looking at intense strength training puts that advice into question.

The study, of nearly 200 women who’d undergone lumpectomy or mastectomy, found that a 3-month weight-training program helped patients make substantial gains in strength, mobility, balance, and body composition.

And while previous studies have examined resistance exercise during breast cancer surgery recovery, this program pumped up the intensity: Most women progressed to deadlifting 100 to 200 pounds, even though few had ever performed strength training before.

“Most of these patients can do a lot more than we think,” said principal investigator Colin Champ, MD, director of the Exercise Oncology and Resiliency Center at Allegheny Health Network in Pittsburgh.

The findings were presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, held in Seattle from April 29 to May 3.

Pumping Up the Intensity

For the analysis, Champ and his colleagues pooled the results of 3 small prospective studies of their strength conditioning program, including one that previously reported no worsening in patients’ lymphedema, and instead, showed signs of improvement.

The researchers evaluated program participants’ physical and functional gains and whether any of those parameters differed by the extent of their breast cancer surgery.

In total, there were 197 participants, including 85 who’d undergone mastectomies and 112 who’d had lumpectomies; 26 patients also had axillary lymph node dissection.

All of the women attended the same 3-month supervised strength-training program, starting at various points in their recovery process. Nearly half started at 3 months postdiagnosis.

According to Champ, the program addresses a full range of motion, with the exercise intensity building over a short period — similar to what professional athletes do in early training. The specific exercises include split squats, dumbbell presses, and dumbbell rows, done 3 days per week, for about 45-60 minutes.

Most participants, Champ said, start with deadlifting around 70 pounds (lifting weight from the floor to hip level). “If you can carry groceries, you can deadlift 60 or 70 pounds,” he noted.

Each month, the weight and sets increase, while the repetitions decrease.

“We just had a woman in her 70s who deadlifted about 200 pounds” as the program progressed, Champ said.

Benefits Regardless of Surgery Type

Women in the current analysis underwent baseline and post-program testing of body composition and functional parameters, including strength, mobility, and balance. Mastectomy patients (median age, 51 years) were younger than lumpectomy patients (median age, 59 years). They were also more likely to have had chemotherapy (45% vs 27%).

Overall, Champ’s team found that both surgery groups showed statistically significant improvements in muscle and body fat percentages over the course of the program, with muscle mass increasing by 1 percentage point on average and body fat declining by 1.5 percentage points.

Similarly, functional movement scores, grip strength, loads lifted, and balance skills also improved, with comparable benefits regardless of surgery type or whether lymph node dissection was performed.

By the end of the program’s third week, Champ said, most women could deadlift 100-pound weights. And by the 3-month mark, many were able to lift 200-pound loads.

Champ called the results empowering, and he hopes they help reframe the traditional mindset that intense strength training is too heavy a lift after breast cancer surgery.

A surgical oncologist who was not involved in the study agreed.

“This gives us something concrete to say to patients,” said Tina Hieken, MD, of the Mayo Clinic in Rochester, Minnesota. “We have more data to say it’s safe for you to exercise.’’

Hieken, who chaired the meeting’s scientific program committee, also noted that the findings pertain to women of all baseline fitness levels.

For her part, Hieken already encourages patients to walk for exercise and spend time outdoors — in part for the mental well-being benefits.

With patients facing so much uncertainty after a cancer diagnosis, she said, “this is something an individual can take control of.”

Champ and Hieken had no disclosures.

A version of this article first appeared on Medscape.com.

Women who undergo surgery for breast cancer often hear that they should take it easy with exercise during recovery. But new research looking at intense strength training puts that advice into question.

The study, of nearly 200 women who’d undergone lumpectomy or mastectomy, found that a 3-month weight-training program helped patients make substantial gains in strength, mobility, balance, and body composition.

And while previous studies have examined resistance exercise during breast cancer surgery recovery, this program pumped up the intensity: Most women progressed to deadlifting 100 to 200 pounds, even though few had ever performed strength training before.

“Most of these patients can do a lot more than we think,” said principal investigator Colin Champ, MD, director of the Exercise Oncology and Resiliency Center at Allegheny Health Network in Pittsburgh.

The findings were presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, held in Seattle from April 29 to May 3.

Pumping Up the Intensity

For the analysis, Champ and his colleagues pooled the results of 3 small prospective studies of their strength conditioning program, including one that previously reported no worsening in patients’ lymphedema, and instead, showed signs of improvement.

The researchers evaluated program participants’ physical and functional gains and whether any of those parameters differed by the extent of their breast cancer surgery.

In total, there were 197 participants, including 85 who’d undergone mastectomies and 112 who’d had lumpectomies; 26 patients also had axillary lymph node dissection.

All of the women attended the same 3-month supervised strength-training program, starting at various points in their recovery process. Nearly half started at 3 months postdiagnosis.

According to Champ, the program addresses a full range of motion, with the exercise intensity building over a short period — similar to what professional athletes do in early training. The specific exercises include split squats, dumbbell presses, and dumbbell rows, done 3 days per week, for about 45-60 minutes.

Most participants, Champ said, start with deadlifting around 70 pounds (lifting weight from the floor to hip level). “If you can carry groceries, you can deadlift 60 or 70 pounds,” he noted.

Each month, the weight and sets increase, while the repetitions decrease.

“We just had a woman in her 70s who deadlifted about 200 pounds” as the program progressed, Champ said.

Benefits Regardless of Surgery Type

Women in the current analysis underwent baseline and post-program testing of body composition and functional parameters, including strength, mobility, and balance. Mastectomy patients (median age, 51 years) were younger than lumpectomy patients (median age, 59 years). They were also more likely to have had chemotherapy (45% vs 27%).

Overall, Champ’s team found that both surgery groups showed statistically significant improvements in muscle and body fat percentages over the course of the program, with muscle mass increasing by 1 percentage point on average and body fat declining by 1.5 percentage points.

Similarly, functional movement scores, grip strength, loads lifted, and balance skills also improved, with comparable benefits regardless of surgery type or whether lymph node dissection was performed.

By the end of the program’s third week, Champ said, most women could deadlift 100-pound weights. And by the 3-month mark, many were able to lift 200-pound loads.

Champ called the results empowering, and he hopes they help reframe the traditional mindset that intense strength training is too heavy a lift after breast cancer surgery.

A surgical oncologist who was not involved in the study agreed.

“This gives us something concrete to say to patients,” said Tina Hieken, MD, of the Mayo Clinic in Rochester, Minnesota. “We have more data to say it’s safe for you to exercise.’’

Hieken, who chaired the meeting’s scientific program committee, also noted that the findings pertain to women of all baseline fitness levels.

For her part, Hieken already encourages patients to walk for exercise and spend time outdoors — in part for the mental well-being benefits.

With patients facing so much uncertainty after a cancer diagnosis, she said, “this is something an individual can take control of.”

Champ and Hieken had no disclosures.

A version of this article first appeared on Medscape.com.

Dual checkpoint blockade allowed 70.6% of patients with microsatellite instability-high (MSI-H) resectable gastric or gastroesophageal junction adenocarcinoma (G/GEJAC) to avoid surgery in a small cohort of the INFINITY study.

MSI-H tumors account for roughly 10% of early G/GEJACs. They respond well to immunotherapy, with high rates of pathologic complete responses. The Italian INFINITY trial set out to test whether some patients with these tumors might not need gastrectomy.

The trial treated MSI-H patients with durvalumab 1500 mg once a month for 3 months along with 1 300-mg dose of the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) blocker tremelimumab on day 1. The 18 patients in cohort 1 proceeded to surgery, with a 60% pathologic complete response rate. An additional 18 patients in cohort 2 were the subject of a presentation at the American Association for Cancer Research (AACR) Annual Meeting 2026. These patients were assessed for clinical complete response; if present, they went on to surveillance; if not, they had surgery.

To qualify for a clinical complete response and surveillance, patients were required to have negative findings on CT and PET scans; tumor-informed circulating tumor DNA (ctDNA); and upper endoscopy with ultrasound, including bite-on-bite biopsies and nodal sampling. Surveillance afterward included CT, endoscopy with biopsies, and ctDNA every 12 weeks for up to 2 years.

Among 17 evaluable patients, 1 withdrew consent during immunotherapy, 13 (76%) had a clinical complete response and started surveillance, and the other 4 went to surgery. One patient in the surveillance group had a local regrowth after 4 months, underwent salvage surgery, and remained disease-free. At a median follow-up of 27.1 months, there were no additional progression events.

Overall, 12 of the 17 patients (70.6%) were gastrectomy-free at 2 years without additional treatment. Progression-free survival was 94.1%, and all patients were alive.

“The results are very encouraging,” lead investigator Alberto Leone, MD, said while presenting the results at the AACR annual meeting.

“Nonoperative management could be a safe and effective strategy for patients achieving a clinical complete response after only 3 months of dual immunotherapy,” said Leone, who is a gastrointestinal medical oncologist at the Istituto Nazionale dei Tumori, Milan, Italy. “However, the optimal strategy needs to be established in larger randomized trials.”

Study discussant Yelena Janjagian, MD, gastrointestinal medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, said the findings were important, particularly given that 70.6% of patients avoided a potentially life-altering gastrectomy.

In addition to surgery, the study also calls into question the need for chemotherapy, long the backbone of management alongside surgery, she said. To replace it, however, “it appears that dual checkpoint blockade will be required for a chemotherapy-free approach to achieve organ preservation.”

“Anti-PD-1 alone is not sufficient; we need CTLA-4 to expand and reactivate tumor-specific immunity,” Janjagian continued.

Ultimately, she expects immunotherapy to shift management of MSI-H cancers away from surgery, although some patients will still likely need an operation.

In addition to being MSI-H, patients in the study were mismatch repair deficient and Epstein-Barr virus-negative with T2/T3 tumors; T4 tumors were excluded.

Tumor-agnostic plasma ctDNA was positive at baseline in 13 patients and cleared in 11 after treatment. Higher baseline plasma ctDNA trended toward a lower likelihood of reaching a clinical complete response. Specificity was 100%, so when positive, the test was “very highly informative,” Leone said.

Three patients had grade 3 adverse events (hyperthyroidism, increased gamma-glutamyl transferase, and colitis) that resolved with steroids. There were no grade 4 events, treatment discontinuation, or deaths.

The work was funded by the GONO Foundation and AstraZeneca, the maker of durvalumab and tremelimumab. Leone reported having no disclosures. Janjagian reported having extensive industry ties, including travel funding, consulting fees, and research support from AstraZeneca.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Alex is also an MIT Knight Science Journalism fellow. Email: aotto@medscape.net 

A version of this article first appeared on Medscape.com.

Dual checkpoint blockade allowed 70.6% of patients with microsatellite instability-high (MSI-H) resectable gastric or gastroesophageal junction adenocarcinoma (G/GEJAC) to avoid surgery in a small cohort of the INFINITY study.

MSI-H tumors account for roughly 10% of early G/GEJACs. They respond well to immunotherapy, with high rates of pathologic complete responses. The Italian INFINITY trial set out to test whether some patients with these tumors might not need gastrectomy.

The trial treated MSI-H patients with durvalumab 1500 mg once a month for 3 months along with 1 300-mg dose of the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) blocker tremelimumab on day 1. The 18 patients in cohort 1 proceeded to surgery, with a 60% pathologic complete response rate. An additional 18 patients in cohort 2 were the subject of a presentation at the American Association for Cancer Research (AACR) Annual Meeting 2026. These patients were assessed for clinical complete response; if present, they went on to surveillance; if not, they had surgery.

To qualify for a clinical complete response and surveillance, patients were required to have negative findings on CT and PET scans; tumor-informed circulating tumor DNA (ctDNA); and upper endoscopy with ultrasound, including bite-on-bite biopsies and nodal sampling. Surveillance afterward included CT, endoscopy with biopsies, and ctDNA every 12 weeks for up to 2 years.

Among 17 evaluable patients, 1 withdrew consent during immunotherapy, 13 (76%) had a clinical complete response and started surveillance, and the other 4 went to surgery. One patient in the surveillance group had a local regrowth after 4 months, underwent salvage surgery, and remained disease-free. At a median follow-up of 27.1 months, there were no additional progression events.

Overall, 12 of the 17 patients (70.6%) were gastrectomy-free at 2 years without additional treatment. Progression-free survival was 94.1%, and all patients were alive.

“The results are very encouraging,” lead investigator Alberto Leone, MD, said while presenting the results at the AACR annual meeting.

“Nonoperative management could be a safe and effective strategy for patients achieving a clinical complete response after only 3 months of dual immunotherapy,” said Leone, who is a gastrointestinal medical oncologist at the Istituto Nazionale dei Tumori, Milan, Italy. “However, the optimal strategy needs to be established in larger randomized trials.”

Study discussant Yelena Janjagian, MD, gastrointestinal medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, said the findings were important, particularly given that 70.6% of patients avoided a potentially life-altering gastrectomy.

In addition to surgery, the study also calls into question the need for chemotherapy, long the backbone of management alongside surgery, she said. To replace it, however, “it appears that dual checkpoint blockade will be required for a chemotherapy-free approach to achieve organ preservation.”

“Anti-PD-1 alone is not sufficient; we need CTLA-4 to expand and reactivate tumor-specific immunity,” Janjagian continued.

Ultimately, she expects immunotherapy to shift management of MSI-H cancers away from surgery, although some patients will still likely need an operation.

In addition to being MSI-H, patients in the study were mismatch repair deficient and Epstein-Barr virus-negative with T2/T3 tumors; T4 tumors were excluded.

Tumor-agnostic plasma ctDNA was positive at baseline in 13 patients and cleared in 11 after treatment. Higher baseline plasma ctDNA trended toward a lower likelihood of reaching a clinical complete response. Specificity was 100%, so when positive, the test was “very highly informative,” Leone said.

Three patients had grade 3 adverse events (hyperthyroidism, increased gamma-glutamyl transferase, and colitis) that resolved with steroids. There were no grade 4 events, treatment discontinuation, or deaths.

The work was funded by the GONO Foundation and AstraZeneca, the maker of durvalumab and tremelimumab. Leone reported having no disclosures. Janjagian reported having extensive industry ties, including travel funding, consulting fees, and research support from AstraZeneca.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Alex is also an MIT Knight Science Journalism fellow. Email: aotto@medscape.net 

A version of this article first appeared on Medscape.com.

Dual checkpoint blockade allowed 70.6% of patients with microsatellite instability-high (MSI-H) resectable gastric or gastroesophageal junction adenocarcinoma (G/GEJAC) to avoid surgery in a small cohort of the INFINITY study.

MSI-H tumors account for roughly 10% of early G/GEJACs. They respond well to immunotherapy, with high rates of pathologic complete responses. The Italian INFINITY trial set out to test whether some patients with these tumors might not need gastrectomy.

The trial treated MSI-H patients with durvalumab 1500 mg once a month for 3 months along with 1 300-mg dose of the cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) blocker tremelimumab on day 1. The 18 patients in cohort 1 proceeded to surgery, with a 60% pathologic complete response rate. An additional 18 patients in cohort 2 were the subject of a presentation at the American Association for Cancer Research (AACR) Annual Meeting 2026. These patients were assessed for clinical complete response; if present, they went on to surveillance; if not, they had surgery.

To qualify for a clinical complete response and surveillance, patients were required to have negative findings on CT and PET scans; tumor-informed circulating tumor DNA (ctDNA); and upper endoscopy with ultrasound, including bite-on-bite biopsies and nodal sampling. Surveillance afterward included CT, endoscopy with biopsies, and ctDNA every 12 weeks for up to 2 years.

Among 17 evaluable patients, 1 withdrew consent during immunotherapy, 13 (76%) had a clinical complete response and started surveillance, and the other 4 went to surgery. One patient in the surveillance group had a local regrowth after 4 months, underwent salvage surgery, and remained disease-free. At a median follow-up of 27.1 months, there were no additional progression events.

Overall, 12 of the 17 patients (70.6%) were gastrectomy-free at 2 years without additional treatment. Progression-free survival was 94.1%, and all patients were alive.

“The results are very encouraging,” lead investigator Alberto Leone, MD, said while presenting the results at the AACR annual meeting.

“Nonoperative management could be a safe and effective strategy for patients achieving a clinical complete response after only 3 months of dual immunotherapy,” said Leone, who is a gastrointestinal medical oncologist at the Istituto Nazionale dei Tumori, Milan, Italy. “However, the optimal strategy needs to be established in larger randomized trials.”

Study discussant Yelena Janjagian, MD, gastrointestinal medical oncologist at Memorial Sloan Kettering Cancer Center in New York City, said the findings were important, particularly given that 70.6% of patients avoided a potentially life-altering gastrectomy.

In addition to surgery, the study also calls into question the need for chemotherapy, long the backbone of management alongside surgery, she said. To replace it, however, “it appears that dual checkpoint blockade will be required for a chemotherapy-free approach to achieve organ preservation.”

“Anti-PD-1 alone is not sufficient; we need CTLA-4 to expand and reactivate tumor-specific immunity,” Janjagian continued.

Ultimately, she expects immunotherapy to shift management of MSI-H cancers away from surgery, although some patients will still likely need an operation.

In addition to being MSI-H, patients in the study were mismatch repair deficient and Epstein-Barr virus-negative with T2/T3 tumors; T4 tumors were excluded.

Tumor-agnostic plasma ctDNA was positive at baseline in 13 patients and cleared in 11 after treatment. Higher baseline plasma ctDNA trended toward a lower likelihood of reaching a clinical complete response. Specificity was 100%, so when positive, the test was “very highly informative,” Leone said.

Three patients had grade 3 adverse events (hyperthyroidism, increased gamma-glutamyl transferase, and colitis) that resolved with steroids. There were no grade 4 events, treatment discontinuation, or deaths.

The work was funded by the GONO Foundation and AstraZeneca, the maker of durvalumab and tremelimumab. Leone reported having no disclosures. Janjagian reported having extensive industry ties, including travel funding, consulting fees, and research support from AstraZeneca.

M. Alexander Otto is a physician assistant with a master’s degree in medical science and a journalism degree from Newhouse. He is an award-winning medical journalist who worked for several major news outlets before joining Medscape. Alex is also an MIT Knight Science Journalism fellow. Email: aotto@medscape.net 

A version of this article first appeared on Medscape.com.

A personalized messenger RNA (mRNA) vaccine for pancreatic cancer continues to show promise for improving patient survival, according to 6-year follow-up results of a phase 1 clinical study.

Among the 8 out of 16 patients in the study who initially experienced an immune response to the vaccine, seven (87.5%) were still alive at follow-up, lead investigator Vinod P. Balachandran, MD, reported at the American Association for Cancer Research (AACR) Annual Meeting 2026.

Of the eight patients who did not respond, two (25%) were still alive, with a median survival time of 3.4 years. “This suggests that personalized vaccines can stimulate the immune system in some pancreatic cancer patients, and that these patients continue to do well for several years after vaccination,” said Balachandran, director of the Olayan Center for Cancer Vaccines at Memorial Sloan Kettering Cancer Center in New York City.

The findings suggest that this vaccine has the potential to improve outcomes in patients with pancreatic cancer, which is one of the deadliest cancers, he said.

The 5-year survival rate for pancreatic cancer is currently 13%, according to the American Cancer Society’s Cancer Statistics 2026 report.

Initial results of the trial evaluating the individualized neoantigen vaccine — autogene cevumeran, which is being developed by BioNTech and Genentech — were published in Nature in February 2025.

After pancreatic cancer surgery and chemo-immunotherapy, patients with pancreatic ductal adenocarcinoma (PDAC) received a vaccine personalized to each patient based on unique changes in their tumor DNA.

The eight patients with vaccine-induced T cells had prolonged recurrence-free survival (RFS; median not reached), whereas nonresponders had a median RFS of 13.4 months, the authors had reported in the Nature paper.

This correlation was not confounded by other factors, including those associated with the patient, tumor, treatment, and host immune fitness, Balachandran noted.

In the responders, the T-cell clones had “high magnitude and exceptional longevity,” with an average estimated lifespan of 7.7 years, he said.

A fundamental challenge in developing cancer vaccines has been generating durable functional T cells specific for tumor antigens, and these findings suggest that mRNA-lipoplex vaccines against somatic mutation-derived neoantigens like autogene cevumeran may help overcome this challenge in pancreatic cancer, he and his colleagues concluded in the Nature paper.

The latest findings presented at the AACR annual meeting further underscore the potential of this approach.

At the 6-year follow-up, median RFS was “still not reached” in the vaccine responders vs 1.1 year in the nonresponders, he noted.

“This translates to a difference in overall survival,” he said. “Seven of eight [responders to the vaccine] are still alive 4.5-6 years after surgery.”

And of the 2 of 8 nonresponders still alive, one appears to be mounting a subclinical vaccine-induced T-cell response, he added, noting that this “suggests that inducible vaccine immunity may also impact survival in PDAC.”

“The implication here, we believe, is that even if a cancer has very mutational by-products [like PDAC], these mutational by-products can empower potent and composite immunity,” he said. “This is important because it could potentially expand vaccine eligibility to many cancers.”

Currently, there are about 50 neoantigen vaccine trials in solid tumors ongoing worldwide, he noted.

Memorial Sloan Kettering reports that Genentech and BioNTech are now testing autogene cevumeran in a larger patient population at numerous sites worldwide.

Balachandran reported receiving research support from Genentech, Merck Sharp & Dohme, and AbbVie.

Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at sworcester@mdedge.com or on X: @SW_MedReporter.

A version of this article first appeared on Medscape.com.

A personalized messenger RNA (mRNA) vaccine for pancreatic cancer continues to show promise for improving patient survival, according to 6-year follow-up results of a phase 1 clinical study.

Among the 8 out of 16 patients in the study who initially experienced an immune response to the vaccine, seven (87.5%) were still alive at follow-up, lead investigator Vinod P. Balachandran, MD, reported at the American Association for Cancer Research (AACR) Annual Meeting 2026.

Of the eight patients who did not respond, two (25%) were still alive, with a median survival time of 3.4 years. “This suggests that personalized vaccines can stimulate the immune system in some pancreatic cancer patients, and that these patients continue to do well for several years after vaccination,” said Balachandran, director of the Olayan Center for Cancer Vaccines at Memorial Sloan Kettering Cancer Center in New York City.

The findings suggest that this vaccine has the potential to improve outcomes in patients with pancreatic cancer, which is one of the deadliest cancers, he said.

The 5-year survival rate for pancreatic cancer is currently 13%, according to the American Cancer Society’s Cancer Statistics 2026 report.

Initial results of the trial evaluating the individualized neoantigen vaccine — autogene cevumeran, which is being developed by BioNTech and Genentech — were published in Nature in February 2025.

After pancreatic cancer surgery and chemo-immunotherapy, patients with pancreatic ductal adenocarcinoma (PDAC) received a vaccine personalized to each patient based on unique changes in their tumor DNA.

The eight patients with vaccine-induced T cells had prolonged recurrence-free survival (RFS; median not reached), whereas nonresponders had a median RFS of 13.4 months, the authors had reported in the Nature paper.

This correlation was not confounded by other factors, including those associated with the patient, tumor, treatment, and host immune fitness, Balachandran noted.

In the responders, the T-cell clones had “high magnitude and exceptional longevity,” with an average estimated lifespan of 7.7 years, he said.

A fundamental challenge in developing cancer vaccines has been generating durable functional T cells specific for tumor antigens, and these findings suggest that mRNA-lipoplex vaccines against somatic mutation-derived neoantigens like autogene cevumeran may help overcome this challenge in pancreatic cancer, he and his colleagues concluded in the Nature paper.

The latest findings presented at the AACR annual meeting further underscore the potential of this approach.

At the 6-year follow-up, median RFS was “still not reached” in the vaccine responders vs 1.1 year in the nonresponders, he noted.

“This translates to a difference in overall survival,” he said. “Seven of eight [responders to the vaccine] are still alive 4.5-6 years after surgery.”

And of the 2 of 8 nonresponders still alive, one appears to be mounting a subclinical vaccine-induced T-cell response, he added, noting that this “suggests that inducible vaccine immunity may also impact survival in PDAC.”

“The implication here, we believe, is that even if a cancer has very mutational by-products [like PDAC], these mutational by-products can empower potent and composite immunity,” he said. “This is important because it could potentially expand vaccine eligibility to many cancers.”

Currently, there are about 50 neoantigen vaccine trials in solid tumors ongoing worldwide, he noted.

Memorial Sloan Kettering reports that Genentech and BioNTech are now testing autogene cevumeran in a larger patient population at numerous sites worldwide.

Balachandran reported receiving research support from Genentech, Merck Sharp & Dohme, and AbbVie.

Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at sworcester@mdedge.com or on X: @SW_MedReporter.

A version of this article first appeared on Medscape.com.

A personalized messenger RNA (mRNA) vaccine for pancreatic cancer continues to show promise for improving patient survival, according to 6-year follow-up results of a phase 1 clinical study.

Among the 8 out of 16 patients in the study who initially experienced an immune response to the vaccine, seven (87.5%) were still alive at follow-up, lead investigator Vinod P. Balachandran, MD, reported at the American Association for Cancer Research (AACR) Annual Meeting 2026.

Of the eight patients who did not respond, two (25%) were still alive, with a median survival time of 3.4 years. “This suggests that personalized vaccines can stimulate the immune system in some pancreatic cancer patients, and that these patients continue to do well for several years after vaccination,” said Balachandran, director of the Olayan Center for Cancer Vaccines at Memorial Sloan Kettering Cancer Center in New York City.

The findings suggest that this vaccine has the potential to improve outcomes in patients with pancreatic cancer, which is one of the deadliest cancers, he said.

The 5-year survival rate for pancreatic cancer is currently 13%, according to the American Cancer Society’s Cancer Statistics 2026 report.

Initial results of the trial evaluating the individualized neoantigen vaccine — autogene cevumeran, which is being developed by BioNTech and Genentech — were published in Nature in February 2025.

After pancreatic cancer surgery and chemo-immunotherapy, patients with pancreatic ductal adenocarcinoma (PDAC) received a vaccine personalized to each patient based on unique changes in their tumor DNA.

The eight patients with vaccine-induced T cells had prolonged recurrence-free survival (RFS; median not reached), whereas nonresponders had a median RFS of 13.4 months, the authors had reported in the Nature paper.

This correlation was not confounded by other factors, including those associated with the patient, tumor, treatment, and host immune fitness, Balachandran noted.

In the responders, the T-cell clones had “high magnitude and exceptional longevity,” with an average estimated lifespan of 7.7 years, he said.

A fundamental challenge in developing cancer vaccines has been generating durable functional T cells specific for tumor antigens, and these findings suggest that mRNA-lipoplex vaccines against somatic mutation-derived neoantigens like autogene cevumeran may help overcome this challenge in pancreatic cancer, he and his colleagues concluded in the Nature paper.

The latest findings presented at the AACR annual meeting further underscore the potential of this approach.

At the 6-year follow-up, median RFS was “still not reached” in the vaccine responders vs 1.1 year in the nonresponders, he noted.

“This translates to a difference in overall survival,” he said. “Seven of eight [responders to the vaccine] are still alive 4.5-6 years after surgery.”

And of the 2 of 8 nonresponders still alive, one appears to be mounting a subclinical vaccine-induced T-cell response, he added, noting that this “suggests that inducible vaccine immunity may also impact survival in PDAC.”

“The implication here, we believe, is that even if a cancer has very mutational by-products [like PDAC], these mutational by-products can empower potent and composite immunity,” he said. “This is important because it could potentially expand vaccine eligibility to many cancers.”

Currently, there are about 50 neoantigen vaccine trials in solid tumors ongoing worldwide, he noted.

Memorial Sloan Kettering reports that Genentech and BioNTech are now testing autogene cevumeran in a larger patient population at numerous sites worldwide.

Balachandran reported receiving research support from Genentech, Merck Sharp & Dohme, and AbbVie.

Sharon Worcester, MA, is an award-winning medical journalist based in Birmingham, Alabama, writing for Medscape, MDedge, and other affiliate sites. She currently covers oncology, but she has also written on a variety of other medical specialties and healthcare topics. She can be reached at sworcester@mdedge.com or on X: @SW_MedReporter.

A version of this article first appeared on Medscape.com.