Decision making and outcomes in colorectal cancer and frailty: the DeCaF study

Surgical resection is the main treatment for non-metastatic colorectal cancer (CRC). However, 6% of patients do not undergo surgery owing to frailty, according to the National Bowel Cancer Audit (NBOCA). The impact of preoperative evaluation and decision making on outcomes in frail patients is underexplored. This study examines variation in decision making for frail, older patients and the availability/use of resources by colorectal multidisciplinary teams (MDTs) across United Kingdom (UK) hospitals.

A UK-wide questionnaire was distributed to colorectal MDTs via the NBOCA newsletter and social media (18 May to 30 June 2021). Part A assessed MDT structure and resource use; Part B explored MDT decisions for two simulated 75-year-old patients with colonic and rectal cancer.

Twenty MDTs responded. Decisions were MDT-driven in 55% (n = 11) and surgeon-driven in 45% (n = 9). Clinical examination (85%) and performance status (90%) were most used. Resource utilisation during MDT meetings varied across sites; for example, echocardiogram results were available and considered in MDT decision making in only 15% of centres. Cardiopulmonary exercise testing was used in 75%, anaesthetic assessment in 80%, frailty scoring in 25%, and preoperative geriatric assessment in 5%. Management of right-sided cancer was more consistent; rectal cancer decisions were more variable.

Variation exists across MDTs in the availability and use of resources when managing frail CRC patients. There is less consensus for rectal than caecal cancer. These findings highlight the need for standardised MDT protocols to support equitable, patient-centred care in complex cases.