The number of older persons in the U.S. diagnosed with an acoustic neuroma/ vestibular schwannoma (VS) is expected to increase significantly as total population grows, life expectancy rates continue to rise, and easy access to MRI diagnostics expands. Median patient age at diagnosis increased from 49.2 years in 1976 to 60 years in 2015. Life expectancy at birth has increased more than 60% since 1900 from about 50 to 80 years. The table below shows the corresponding increase in life expectancy for seniors at age 65 for the period 1980-2020.
|Date||White Male||White Female||Black Male||Black Female|
National Center for Health Statistics
There are many single-institution medical journal reports comparing surgical outcomes for older and younger acoustic neuroma (VS) patients. The present article provides a sampling of reports available to read (in abstract or sometimes full text) at www. PubMed.gov.
- Researchers at the University of Utah, Clinical Neurosciences Center, asked (2016): “Does age matter?” They reviewed their records for patients (>65 years) treated for VS, 2000-2012. The average tumour size was 16.5 mm.
They found no significant differences in surgical complications, facial nerve outcome, or hearing preservation rates between 23 older and 220 younger patients.” They concluded: Age alone may not be an absolute contraindication to surgical management of VS. Other factors need to be considered, such as general health, tumour size, surgical approach and preoperative hearing.
A Mayo Clinic study (2014) compared outcomes for 20 surgery patients 70-86 years old and a matched group of younger adults 25-69 years old. The mean tumour size was approximately 3 cm. Overall, the elderly patients had poorer preoperative physical status and were 13 times more likely to have long-term post-operative imbalance. There were no differences in surgery related complications or facial nerve function. For the elderly patients, there was a high risk of further tumour growth following STR (subtotal removal); six patients required intervention for tumour remnants after STR.
The acoustic neuroma team at the University of California/San Francisco reported (2003) on the effect of age on hearing preservation, facial nerve outcome, and complication rates following surgery. 150 older patients (>60 years) were compared with 55 younger patients (< 40 years). The team found that there is a lower chance of preserving good hearing in older patients but age was not associated with a difference in the rate of good facial outcome. There was a trend toward slightly higher rates of cerebrospinal fluid leak in the older patient group but no difference in the rate of other complications. The team also looked specifically at outcomes in an attempt for hearing preservation. Age, they found, was associated with a lower rate of preservation of good hearing.
The University Health Service Consortium compiles a national inpatient discharge database that can be queried for information about VS surgery patients treated at nearly all academic medical centers and hundreds of U.S. hospitals. Researchers at the Medical University of South Carolina, Charleston, used this national UHC database to identify and analyze 3,697 VS surgical cases for a 3-year time span, 2012-2015.
Surgical outcomes, such as length of stay (LOS), complications, and mortality, were analyzed on the basis of race, sex, age and comorbidities during the 30-day postoperative period.
The overall mortality rate was 0.38%, and the overall complication rate was 5.3%. Advanced age significantly affected intensive care unit LOS, mortality, and complications. Comorbidities, including hypertension, obesity, and depression also significantly increased complication rates.
Modern VS surgery has a low mortality rate and a relatively low rate of complications.
Specific information that is key to VS surgery including tumour size, individual institution case volume, surgical approach, facial nerve function, and hearing status is unfortunately not available through this database. The study only involved the 30-day postoperative period which precludes long-term data. Weight loss, a comorbidity associated with advanced age and/or chronic illness, was associated with much poorer outcomes. African Americans were found to have a higher complication rate than other races in this study. However, a statewide study of general surgical complications in African American patients found it was mostly due to an increased prevalence of comorbidities. As results and other studies demonstrate, the potential benefits of watching and waiting in the older population must be balanced against the risks of having surgery at advanced age.
The University of South Carolina researchers have also used the UHC national database to investigate the extent to which institutions that perform higher volumes of VS surgery (HVHs) have lower complication rates, shorter LOS, and more routine discharges. For outcomes, the focus is on the importance of surgeon experience rather than patient age.
This article, reprinted with permission, first appeared in the ANA New Jersey Newsletter March 2022.