Geriatric oncology

Major Invasive Surgery for Urologic Cancer in Octogenarians with Comorbid Medical Conditions

OBJECTIVES

We retrospectively reviewed the records of the octogenarian patients who underwent major surgery for urologic cancer at two institutions. The aims of our study were to assess intra- and postoperative morbidity and mortality rates, and to identify potential risk factors that can predict postoperative complications and, as a consequence, surgical outcome.

METHODS

Fifty-five patients (median age: 83 yr) underwent major surgery for urologic cancer. Radical nephrectomy was performed in 27 patients, radical cystectomy with urinary diversion was done in 20 patients, and nephroureterectomy was performed in the remainder. Significant comorbidity was present in 51 patients.

RESULTS

The perioperative mortality rate was 9%. The overall mortality rate was 69%; cancer-specific mortality was 28%. Intraoperative complications occurred in 11% of patients. Postoperative intensive care monitoring was required in 29% of patients. The early postoperative complication rate was 33%. Only the presence of more than two comorbidities (p<0.05) and chronic obstructive lung disease (COLD) (p=0.017) resulted in independent prognostic factors for morbidity. Sixteen percent of patients developed a late postoperative complication within the first 6 mo. Median hospital stay was 14 d (range: 6-55), and hospital stays were significantly longer among patients with complications (p<0.05). The 3-yr and 5-yr overall survival rates were 36% and 26%, respectively; these rates were significantly lower in patients with COLD (p<0.01). There was no significant difference between cancer-specific and non-cancer-specific survival rates.

CONCLUSIONS

Major surgery for urologic malignancies can be safely performed in selected octogenarian patients.

Steroidal aromatase inhibitors in elderly patients

The choice of treatment for elderly breast cancer patients needs particular care because the presence of physiological functional impairments can modify the drug bioavailability in an unpredictable manner. Hormonal treatment remains one of the choices and, although tamoxifen has proved to be effective in any setting, the use of selective aromatase inhibitors is arousing. Depending on their chemical structure, aromatase inhibitors are either steroidal (such as exemestane and formestane) or non-steroidal (such as letrozole, vorozole and anastrozole). Formestane has been studied in elderly patients with breast cancer and has been found to induce an overall response rate of 51% (95% CI, 35-67%). The drug suppresses estradiol (E2) levels, and changes in other hormones (FSH, LH and SHBG) are observed, but with poor clinical significance, thus confirming its selectivity and potency. Formestane has also been demonstrated to be as effective as tamoxifen. Exemestane and non-steroidal aromatase inhibitors appear to be very promising drugs.

Radical nephrectomy and nephroureterectomy in the octogenarian and nonagenarian: comparison of laparoscopic and open approaches

OBJECTIVES

To retrospectively compare the outcome of laparoscopic and open radical nephrectomy or nephroureterectomy in patients 80 years old or older, inasmuch as the tolerance profile of major laparoscopic renal surgery in comparison to open surgery in the elderly patient has not been previously reported.

METHODS

Since September 1997, 11 patients 80 years old or older underwent retroperitoneal laparoscopic radical nephrectomy or nephroureterectomy for cancer. These patients were compared with 6 consecutive patients 80 years old or older who underwent comparable open surgery at our institution since January 1994. No tumor had computed tomographic evidence of lymphatic, vascular, or perirenal extension.

RESULTS

Baseline parameters were comparable between the laparoscopic and open groups. The laparoscopic group had a similar median surgical time (210 minutes versus 175 minutes; P = 0.1) and blood loss (150 mL versus 125 mL; P = 0.8) compared with the open group. However, specimen weight was larger in the laparoscopic group (568 g versus 292 g; P = 0.04). Moreover, the laparoscopic group had a quicker resumption of oral intake (less than 1 day versus 4 days; P <0.001), decreased narcotic requirements (14 mg versus 326 mg; P = 0.004), shorter hospital stay (2 days versus 6 days; P <0.001), and faster convalescence (14 days versus 42 days; P <0.001) compared with the open group.

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy and nephroureterectomy are well tolerated by the elderly patient. Although our sample size was small, it appears that laparoscopy is an excellent alternative to open surgery for excision of selected renal malignancies in the octogenarian and nonagenarian population.

Features of cancer in nonagenarians and centenarians

OBJECTIVE

To describe the incidence rates and sites of cancer, the causes of death, and gender and ethnic variations in patients with cancer in a population of people 90 years of age and older.

DESIGN

Analysis of the 14,088 cases of cancer in this age group, accessioned by the California Cancer Registry from 1988 through 1993, and comparison with those less than age 90.

MEASUREMENTS

Incidence rates and numbers and percents of cases with various features (gender, ethnicity, site of tumor, stage, causes of death).

RESULTS

The peak age-specific incidence (ASI) of cancer is in the group 80 to 84 years of age. Those 90 to 94 years of age had a higher ASI than any group except those ages 75 to 89. There are ethnic variations in the sites of cancer in people aged 90 or older. Colorectal cancer accounts for more than one-fifth of the new cases of cancer in people 90 or older. In women aged 90 or older, the most common sites of cancers are colorectal, breast, and lymphoma/leukemia. In men of the same age, prostate, colorectal, and lung/bronchus are the most common sites. As age increases, fewer people have their cancers staged, and for lung/bronchus, prostate, and breast, more cancers are first diagnosed in the distant stage in people aged 90 and older. Of the people with cancer who die, the proportion dying of cancer decreases as age increases.

CONCLUSION

Cancer is a common disease in nonagenarians and centenarians and will be an increasing healthcare problem. Knowledge of its features is essential to those planning, delivering, and financing health care.

Radical cystectomy in the octogenarian

PURPOSE

We evaluated the morbidity and outcome of cystectomy and urinary diversion in patients 80 years old or older with invasive bladder cancer.

MATERIALS AND METHODS

We reviewed the records of all patients older than 80 years who underwent cystectomy during the last 15 years. Of 1,186 cystectomies 44 patients (4%) were identified. Patients were evaluated for complications, mortality and functional status after surgery.

RESULTS

The 44 patients had a median age of 81 years (range 80 to 87). Of the patients 78% had significant co-morbidity, including 41% with 2 or more medical problems. Median hospital stay was 14 days, with 20% of the patients requiring intensive care for 24 hours. There was a 51% complication rate including 25% due to surgical complications and 26% from underlying medical illness. Operative mortality was 4.5%. Within 6 months of surgery 66% were rehospitalized for medical or surgical reasons. Median survival time was 25 months. Median performance status before and after surgery decreased slightly from 70 to 65.

CONCLUSIONS

The results of this study support the use of cystectomy in octogenarians with invasive bladder cancer. Surgery can be accomplished with acceptable morbidity and mortality. Radical cystectomy in this population offers the best opportunity for sustained disease-free quality survival.

Medical oncology and geriatric medicine: is it time for fellowship integration?

Although training programs exist in both medical oncology and geriatrics (approved by the American Board of Internal Medicine), neither is adequate to ensure an appropriate supply of physicians to assume a leadership role in the treatment of the increasing number of geriatric patients who have or will develop a malignancy. A proposal for offering a 3-4 year program leading to dual certification is under consideration. A careful review of both the medical oncology training program and added qualifications in geriatrics has identified key components of each that can serve as a basis for a combined program. Such a program can encourage research into behavior modification of existing biases in referring geriatric oncology patients for treatment as well as a better understanding of the biology of aging, addressing in particular the pharmacology of anticancer agents in this unique population. It is anticipated that pilot projects will be undertaken to develop common pathways for developing combined programs in medical oncology and geriatrics. The second phase will include recruitment of selected candidates who are interested in an academic career in geriatric oncology. A need for additional academic-based geriatric oncologists has been identified that can address the anticipated increase in the incidence and presence of cancer in an aging population. Such a cadre of specialists will be in an excellent position to recommend changes in the current (mostly negative) approach to the management of cancer in patients age > 65 years.