Inside the black box: Associations between psychosocial factors and surgical outcomes in older patients undergoing cancer surgery – A pilot study

INTRODUCTION: As the number of adults aged ≥80 undergoing cancer surgery increases, predicting postoperative outcomes remains difficult. Traditional risk tools often fail to capture psychosocial and subjective health factors, contributing to the so-called "black box effect"-unexplained variation in outcomes despite similar clinical profiles. Emerging evidence suggests that wellbeing, symptom burden, and loneliness may influence recovery and survival, yet these factors are rarely assessed preoperatively. Our primary objective was to examine associations between baseline functional, psychosocial, and symptom-related characteristics and postoperative outcomes in cognitively intact adults aged ≥80 years undergoing elective cancer surgery. A secondary objective was to characterize functional independence and psychosocial health in this patient population. MATERIALS AND METHODS: In this prospective single-center pilot study, 55 patients consented between 2018 and 2021, of whom 51 with a Montreal Cognitive Assessment (MoCA) score > 25 were included. Participants underwent structured preoperative assessments covering cognitive function (MoCA), functional independence (Barthel Index), symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial factors (Sense of Coherence Scale, loneliness, Social Provision Scale, Self Transcendence Scale, Geriatric Depression Scale), and health-related quality of life (HRQoL) (RAND-12). Clinical data, surgical characteristics, postoperative complications (Clavien-Dindo II-V), length of stay (LOS), and overall survival (OS) were recorded. Multivariable logistic, linear, and Cox regression models were used to examine independent associations between candidate variables and postoperative outcomes. RESULTS: Most patients demonstrated high baseline functioning, low depressive symptoms, and preserved HRQoL. Nonetheless, 24% reported frequent loneliness. Postoperative complications occurred in 45% of patients, and 18% experienced major complications. Lower ESAS wellbeing scores independently predicted postoperative complications (OR 1.32 per point). Longer LOS was associated with complications, surgical approach, and frequent loneliness, the latter corresponding to approximately 60% longer LOS. Five-year OS was 71% for localized disease, 41% for locally advanced disease, and 13% for metastatic disease. In the final Cox model, increasing age, locally advanced disease, and frequent loneliness (HR 3.56) independently predicted reduced OS. DISCUSSION: Poorer self-rated wellbeing and frequent loneliness were independently associated with adverse postoperative outcomes, including complications, prolonged hospital stay, and reduced survival, even in this functionally robust older surgical population. As a pilot study, these findings are hypothesis-generating and require validation in larger, adequately powered cohorts before informing clinical practice.