Curative surgery for colorectal cancer: long-term results and life expectancy in the elderly

Survival of surgical and non-surgical older patients with non-metastatic colorectal cancer: A population-based study in the Netherlands

BACKGROUND

Surgery is the primary treatment for non-metastatic colorectal cancer (CRC) but is omitted in a proportion of older patients. Characteristics and prognosis of non-surgical patients are largely unknown.

OBJECTIVE

To examine the characteristics and survival of surgical and non-surgical older patients with non-metastatic CRC in the Netherlands.

METHODS

All patients aged ≥70 years and diagnosed with non-metastatic CRC between 2014 and 2018 were identified in the Netherlands Cancer Registry. Patients were divided based on whether they underwent surgery or not. Three-year overall survival (OS) and relative survival (RS) were calculated for both groups separately. Relative survival and relative excess risks (RER) of death were used as measures for cancer-related survival.

RESULTS

In total, 987/20.423 (5%) colon cancer patients and 1.459/7.335 (20%) rectal cancer patients did not undergo surgery. Non-surgical treatment increased over time from 3.7% in 2014 to 4.8% in 2018 in colon cancer patients (P = 0.01) and from 17.1% to 20.2% in rectal cancer patients (P = 0.03). 3 year RS was 91% and 9% for surgical and non-surgical patients with colon cancer, respectively. For rectal cancer patients this was 93% and 37%, respectively. In surgical patients, advanced age (≥80 years) did not decrease RS (colon; RER 0.9 (0.7-1.0), rectum; RER 0.9 (0.7-1.1)). In non-surgical rectal cancer patients, higher survival rates were observed in patients treated with chemoradiotherapy (OS 56%, RS 65%), or radiotherapy (OS 19%, RS 27%), compared to no treatment (OS 9%, RS 10%).

CONCLUSION

Non-surgical treatment in older Dutch CRC patients has increased over time. Because survival of patients with colon cancer is very poor in the absence of surgery, this treatment decision must be carefully weighed. (Chemo-)radiotherapy may be a good alternative for rectal cancer surgery in older frail patients.

Multicenter phase III randomized trial comparing laparoscopy and laparotomy for colon cancer surgery in patients older than 75 years: the CELL study, a Fédération de Recherche en Chirurgie (FRENCH) trial

Background

Several multicenter randomized controlled trials comparing laparoscopy and conventional open surgery for colon cancer have demonstrated that laparoscopic approach achieved the same oncological results while improving significantly early postoperative outcomes. These trials included few elderly patients, with a median age not exceeding 71 years. However, colon cancer is a disease of the elderly. More than 65% of patients operated on for colon cancer belong to this age group, and this proportion may become more pronounced in the coming years. In current practice, laparoscopy is underused in this population.

Methods

The CELL (Colectomy for cancer in the Elderly by Laparoscopy or Laparotomy) trial is a multicenter, open-label randomized, 2-arm phase III superiority trial. Patients aged 75 years or older with uncomplicated colonic adenocarcinoma or endoscopically unresectable colonic polyp will be randomized to either colectomy by laparoscopy or laparotomy. The primary endpoint of the study is overall postoperative morbidity, defined as any complication classification occurring up to 30 days after surgery. The secondary endpoints are: 30-day and 90-day postoperative mortality, 30-day readmission rate, quality of surgical resection, health-related quality of life and evolution of geriatric assessment. A 35 to 20% overall postoperative morbidity rate reduction is expected for patients operated on by laparoscopy compared with those who underwent surgery by laparotomy. With a two-sided α risk of 5% and a power of 80% (β = 0.20), 276 patients will be required in total.

Discussion

To date, no dedicated randomized controlled trial has been conducted to evaluate morbidity after colon cancer surgery by laparoscopy or laparotomy in the elderly and the benefits of laparoscopy is still debated in this context. Thus, a prospective multicenter randomized trial evaluating postoperative outcomes specifically in elderly patients operated on for colon cancer by laparoscopy or laparotomy with curative intent is warranted. If significant, such a study might change the current surgical practices and allow a significant improvement in the surgical management of this population, which will be the vast majority of patients treated for colon cancer in the coming years.

Trial registration

ClinicalTrials.gov NCT03033719 (January 27, 2017).

Age at death and the effect of lead-time bias in patients with colorectal cancer: a 10-year follow-up

AIM

Studies addressing the benefit of early intervention are prone to lead-time bias, which results in an artificial improvement in cancer-specific mortality. We have previously compared the age at death for patients with colorectal cancer presenting on an emergency or elective basis. In this study, we aimed to repeat the analysis with a minimum follow-up of 10 years.

METHOD

A nonscreen-detected cohort of patients presenting with colorectal cancer to three Lanarkshire Hospitals between 2000 and 2006 were entered into a prospective database, with analysis performed on 28 November 2016. The following data were collected: age at death, presentation type (emergency/elective), operative intent (palliative/curative) and Dukes stage. Results are presented as [mean (95% confidence intervals)]. Statistical analysis was undertaken using Student's t-test and multivariate analysis performed using Cox proportional hazard models.

RESULTS

One thousand six hundred and thirty-six patients were identified. Elective patients presented younger than emergency patients [67.9 (67.3-68.5) vs 70.9 (69.6-72.2) years; P < 0.0001]. Overall mortality was 71.1% at time of analysis; no difference was seen in the mean age at death between emergency and elective presentation [73.5 (72.4-74.8) vs 73.6 (72.3-74.9) years; P = 0.841].

CONCLUSION

Current early detection strategies to diagnose colorectal cancer may improve cancer-specific survival by increasing lead-time bias. However, in our cohort of symptomatic patients, treatment on an elective or emergency basis does not influence overall survival. These data suggest that in selected patients, particularly where there is comorbidity, it may be reasonable to adopt a more expectant approach to investigate and treat colorectal symptoms.

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

PURPOSE

The number of patients aged ≥ 90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥ 90 years.

METHODS

We retrospectively reviewed the medical records of 100 patients (aged ≥ 90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

RESULTS

The patients who underwent tumor resections (n = 71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n = 29) (median overall survival time: 23.92 months vs. 2.99 months, P < 0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n = 27) and elective open (n = 37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p = 0.0179).

CONCLUSIONS

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥ 90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

Role of surgery for colorectal cancer in the elderly

The prevalence of subjects with colorectal cancer is expected to grow in the next future decades and surgery represents the most successful treatment modality for these patients. Anyway, currently elderly subjects undergo less elective surgical procedures than younger patients mainly due to the high rates of postoperative morbidity and mortality. Some authors suggest extensive surgery, including multistage procedures, as carried out in younger patients while others promote less aggressive surgery. In older patients, laparoscopic-assisted colectomy showed a number of advantages compared to conventional open surgery that include lower stress, higher rate of independency after surgery, quicker return to prior activities and a decrease in costs. The recent advances in chemotherapy and the introduction of new surgical procedures such as the endoluminal stenting, suggest the need for a revisitation of surgical practice patterns and the role of palliative surgery, mainly for patients with advanced disease. In this article, we discuss the current role of surgery for elderly patients with colorectal cancer.

Surgery for Colorectal Cancer in Elderly Patients: How Could We Improve Early Outcomes ?

BACKGROUND

Age is one of the causes behind the undertreatment of elderly colorectal cancer patients. The increase of mortality among elderly colorectal cancer (CRC) patients is due to competing causes of death occurring in the early post operative period. The purpose of this study was to evaluate the risk factors for post operative mortality and morbidity among elderly CRC patients.

MATERIALS AND METHODS

A retrospective descriptive chart review was performed on consecutive patients older than 70 y with CRC. We have collected data of 124 patients who were admitted from January 2001 to January 2010. Demographic characteristics, operative and postoperative informations were retrospectively analysed.

RESULTS

Early postoperative morbidity, operation related to morbidity and mortality were observed in 44 (35.5%), 9 (7.3%) and 20 (16.1%) cases, respectively. No other factors but ASA score (p = 0.002 and 0.005 in univariate and multivariate analyses, respectively) and emergency operations (p<0.001 and 10(-3) in univariate and multivariate analyses, respectively), were found to be risk factors of mortality. The results of multivariate analyses indicated that anaemia (p=0.021) and rectal cancer (p=0.015) had significant impact on the risk of anastomotic leakage. On the other hand, diabetes mellitus and rectal cancer were indicators that correlated with the width of hospitalization.

CONCLUSION

Elderly CRC patients should no longer be undertreated only because of their age. They should be exposed to more aggressive management than they are currently receiving. Careful preoperative evaluation, followed by medical optimization and planning of perioperative care could improve outcomes of colorectal surgery for elderly patients.

Curative colorectal resections in patients aged 80 years and older: clinical characteristics, morbidity, mortality and risk factors

BACKGROUND

The management of colorectal cancer in the elderly presents unique challenges. The objective of this study was to determine outcomes following curative colorectal resection in patients aged 80 years and older.

PATIENTS AND METHODS

Study design is retrospective. Data were extracted from the university hospital database and medical records of patients aged 80 years and older operated between April 2004 and December 2009. Intervention was curative colorectal resection. Main outcome measures include postoperative morbidity, mortality and individual risk factors associated with them.

RESULTS

Three hundred fifty-eight patients (43.8% males, age = 84 ± 3 years) were included; 72.6% received elective surgery. A significantly higher complication rate and 30 day, 1 year and 4 year mortality were present for emergency operations compared to elective (p < 0.001). One-year survival was 65.0% for elective resections and 55.1% for emergency. At 4 years of follow-up, survival was 49.2% for the elective vs. 27.6% for emergency. The American Society of Anesthesiologists (ASA) score is the only factor associated with the 30-day mortality at the multivariate analysis (p < 0.01), Dukes staging with overall mortality (p < 0.005), sex and mode of the operation with major complications (p < 0.05). A limitation of the study is that is retrospective.

CONCLUSIONS

The highest mortality rates following colorectal surgery in the elderly are in the early postoperative period, especially for emergency operations and patients with significant comorbidities. However, the 1-year survival following elective curative resection for colorectal cancer approaches 65 %. ASA score and modality of the operation (elective vs. emergency) impacted on postoperative mortality and morbidity and could be used to select patients with more favourable outcomes.

Elderly patients with colon cancer have unique tumor characteristics and poor survival

BACKGROUND

The incidence of colon cancer increases with age, and colon cancer predominantly affects individuals >65 years old. However, there are limited data regarding clinical and pathologic factors, treatment characteristics, and survival of older patients with colon cancer. The objective of this study was to determine the effects of increasing age on colon cancer.

METHODS

Patients diagnosed with colon cancer between 1988 and 2006 were identified through the Los Angeles County Cancer Surveillance Program, in Southern California. Patients were stratified into 4 age groups: 18-49, 50-64, 65-79, and ≥80 years. Clinical and pathologic characteristics and disease-specific and overall survival were compared between patients from different age groups.

RESULTS

A total of 32,819 patients were assessed. Patients aged 18 to 49 and 65 to 79 years represented the smallest and largest groups, respectively. A near equal number of males and females were diagnosed with colon cancer in the 3 youngest age groups, whereas patients who were ≥80 years old were more commonly white and female. Tumor location was different between groups, and the frequency of larger tumors (>5 cm) was greatest in youngest patients (18-49 years). The oldest patients (≥80 years) were administered chemotherapy at the lowest frequency, and disease-specific and overall survival rates decreased with increasing age.

CONCLUSIONS

This investigation demonstrates that older age is associated with alterations in clinical and pathologic characteristics and decreased survival. This suggests that the phenotype of colon cancer and the efficacy of colon cancer therapies may be dependent on the age of patients.

Surgical treatment of colon cancer in patients aged 80 years and older : analysis of 31,574 patients in the SEER-Medicare database

BACKGROUND

Age-related disparities in colon cancer treatment exist, with older patients being less likely to receive recommended therapy. However, to the authors' knowledge, few studies to date have focused on receipt of surgery. The objective of the current study was to describe patterns of surgery in patients aged ≥ 80 years with colon cancer and examine outcomes with and without colectomy.

METHODS

Medicare beneficiaries aged ≥ 80 years with colon cancer who were diagnosed between 1992 and 2005 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariable logistic regression analysis was used to assess factors associated with nonoperative management. Kaplan-Meier survival analysis determined 1-year overall and colon cancer-specific survival.

RESULTS

Of 31,574 patients, 80% underwent colectomy. Approximately 46% were diagnosed during an urgent/emergent hospital admission, with decreased 1-year overall survival (70% vs 86% for patients diagnosed during an elective admission) noted among these individuals. Factors found to be most predictive of nonoperative management included older age, black race, more hospital admissions, use of home oxygen, use of a wheelchair, being frail, and having dementia. For both operative and nonoperative patients, the 1-year overall survival rate was lower than the colon cancer-specific survival rate (operative patients: 78% vs 89%; nonoperative patients: 58% vs 78%).

CONCLUSIONS

The majority of older patients with colon cancer undergo surgery, with improved outcomes noted compared with nonoperative management. However, many patients who are not selected for surgery die of unrelated causes, reflecting good surgical selection. Patients undergoing surgery during an urgent/emergent admission have an increased short-term mortality risk. Because the earlier detection of colon cancer may increase the percentage of older patients undergoing elective surgery, the findings of the current study may have policy implications for colon cancer screening and suggest that age should not be the only factor driving cancer screening recommendations.

Age at death of patients with colorectal cancer and the effect of lead-time bias on survival in elective vs emergency surgery

AIM

Colorectal cancer survival depends on stage at presentation, and current strategies aim for improvements through early detection. Previous studies have demonstrated improved survival from diagnosis but not increased life expectancy. While lead-time bias may account for variations in known prognostic indicators and also influence screening programmes, only age at death provides a true representation of the effectiveness of an intervention. We aimed to compare age at death for patients with colorectal cancer presenting on an emergency or elective basis.

METHOD

Patients presenting with colorectal cancer (2000-2006) were entered into a prospective database (analysis 1 December 2008). Fields included age at death, emergency/elective presentation, palliative/curative intent and disease stage.

RESULTS

One thousand six hundred and fifty patients (922 men) were identified. Elective patients presented younger than emergency patients (67.9 vs 70.6 years; P < 0.005). Dukes B patients presented older than Dukes D (P = 0.02). Mortality was 41% at time of analysis; no difference was seen in mean age at death between emergency and elective presentation (72.8 vs 72.0 years; P = 0.379) or palliative and curative intent (72.0 vs 72.5 years; P = 0.604).

CONCLUSION

Colorectal cancer is common in a population where actuarial life expectancy is limited. Current colorectal cancer early detection strategies may improve cancer-specific survival by increasing lead-time bias but do not influence overall life expectancy.

Importance of the first postoperative year in the prognosis of elderly colorectal cancer patients

Background

Elderly colorectal cancer patients have worse prognosis than younger patients. Age-related survival differences may be cancer or treatment related, but also due to death from other causes. This study aims to compare population-based survival data for young (<65 years), aged (65–74 years), and elderly (≥75 years) colorectal cancer patients.

Methods

All patients operated for stage I–III colorectal cancer between 1991 and 2005 in the western region of The Netherlands were included. Crude survival, relative survival, and conditional relative survival curves, under the condition of surviving 1 year, were made for colon and rectal cancer patients separately. Furthermore, 30-day, 1-year, and 1-year excess mortality data were compared.

Results

A total of 9,397 stage I–III colorectal cancer patients were included in this study. Crude survival curves showed clear survival differences between the age groups. These age-related differences were less prominent in relative survival and disappeared in conditional relative survival (CRS). Only in stage III disease did elderly patients have worse CRS than young patients. Furthermore, significant age-related differences in 30-day and 1-year excess mortality were found. Thirty-day mortality vastly underestimated 1-year mortality for all age groups.

Conclusions

Elderly colorectal cancer patients who survive the first year have the same cancer-related survival as younger patients. Therefore, decreased survival in the elderly is mainly due to differences in early mortality. Treatment of elderly colorectal cancer patients should focus on perioperative care and the first postoperative year.

Outcome of colonic surgery in elderly patients with colon cancer

Introduction. Colonic cancer is one of the most commonly diagnosed malignancies and most often occurs in patients aged 65 years or older. Aim. To evaluate the outcome of colonic surgery in the elderly in our hospital and to compare five-year survival rates between the younger and elderly patients. Methods. 207 consecutive patients underwent surgery for colon cancer. Patients were separated in patients younger than 75 and older than 75 years. Results. Elderly patients presented significantly more (P < .05) as a surgical emergency, had a longer duration of admission and were more often admitted to the ICU (P < .01). Also, elderly patients had significant more co-morbidities, especially cardiovascular pathology (P < .01). Post-operative complications were seen more often in the elderly, although no significant difference was seen in anastomotic leakage. The five-year survival rate in the younger group was 62% compared with 36% in the elderly (P < .05). DFS was 61% in the younger patients compared with 32% in the elderly (P < .05). Conclusion. Curative resection of colonic carcinoma in the elderly is well tolerated and age alone should not be an indication for less aggressive therapy. However, the type and number of co-morbidities influence post-operative mortality and morbidity.

Caring for octogenarian and nonagenarian patients with colorectal cancer: what should our standards and expectations be?

PURPOSE

Octogenarians and nonagenarians constitute a rapidly growing segment of patients undergoing colorectal cancer resection. We describe their outcomes in a large population cohort and aim to establish expectations and improvements for their care.

METHODS

All patients undergoing surgical resection for colorectal cancer in California (1994-2005) were identified in the California Cancer Registry, which was linked with the California Office of Statewide Health Planning and Development Patient Discharge Database and the 2000 United States Census. Multivariate logistic regression was used to determine significant outcome predictors.

RESULTS

Octogenarians and nonagenarians comprised 26% of all patients undergoing colon cancer resection and 16% of all patients undergoing rectal cancer resection from 1994 to 2005. This cohort had more comorbidities but less distant disease than patients <65 years old (P < .001). Twelve percent of patients with rectal cancer and 17% of patients with colon cancer who were 80 years or older had emergent surgery vs 5% and 12%, respectively, for patients <65 years old (P < .001). Patients 80 years or older had nearly twice the readmission incidence rate (417 readmissions per thousand patient-years) of patients <65 years old. Twenty-seven percent of 90-day readmissions were for surgical complications, 52% of which required a subsequent procedure. Patients 80 years or older had high in-hospital mortality (6%) and one-year mortality (29%). Medical complications, increasing comorbidities, and cancer stage were predictive of in-hospital and 1-year mortality.

CONCLUSIONS

: Octogenarians and nonagenarians represent a large segment of patients with colorectal cancer undergoing surgical resection with high rates of morbidity, mortality, and readmission. Medical optimization and excellent continuity of care may contribute to improved outcomes following surgery for these complex patients.

Merging Claims Databases with a Tumor Registry to Evaluate Variations in Cancer Mortality: Results from a Pilot Study of 698 Colorectal Cancer Patients Treated at One Hospital in the 1990s

BACKGROUND

Prognostic models are essential for evaluating variations in cancer mortality statistics. While cancer stage is the most widely accepted and commonly used predictor of survival for cancer, electronic claims databases contain large amounts of information on cancer patients. Previous studies have used Medicare databases and tumor registry information from the Surveillance Epidemiology and End Results data sets to evaluate variations in outcomes for older cancer patients. We evaluated if similar analytic efforts could be carried out with readily available data sets for colorectal cancer patients of all ages who received care at a single hospital during the 1990s.

METHODS

Hospital tumor registry and discharge claims data for patients at one mid-western hospital with surgically treated stage I-III colorectal cancer from 1990-1998 were used to model survival. Kaplan-Meier logrank tests and Cox proportional hazards models tested the statistical significance of demographic, operative, and clinicopathological factors as predictors of survival. Survival probabilities also were compared to U.S. population life table data to determine if survival deficits were larger for younger cancer patients.

RESULTS

Of the 698 colorectal cancer patients, overall five-year survival probability was 65%, with a median follow-up of 44.7 months. Factors associated with higher relative risks of death included sociodemographic characteristics [female gender (1.5, 95% CI: 1.1-1.9), ages 70-79 years (1.7, 95% CI: 1.2-2.3), and > or = 80 years (3.3, 95% CI: 2.4-4.7) as compared to younger patients], clinical characteristics [moderate (1.5, 95% CI: 1.1-2.1) or severe (2.1, 95%: 1.4-3.2) comorbid illness, as compared to mild or no comorbid illnesses and emergency admission (2.1, 95% CI: 1.5-2.9)], pathological characteristics [positive surgical margins (3.5, 95% CI: 2.3-5.3): and higher cancer stage (stage II RR = 1.5, 95% CI = 1.1-2.2; stage III RR = 2.2, 95% CI = 1.5-3.2), as compared to stage I]. A comparison to the age- and gender-matched survival probabilities of the general population demonstrated similar deficits in survival for older patients (> or = 70 years) and younger patients (< 70 years).

CONCLUSIONS

While cancer stage is a reliable predictor of survival, other sociodemographic and clinical data elements can improve the evaluation of expected survival rates for patients with surgically resectable colorectal cancers. To facilitate comparative interpretations of mortality data, consideration should be given to merging hospital discharge claims data sets with tumor registry information in a manner analogous to that which has been done for older cancer patients who are covered by the Medicare program.

The United Kingdom National Bowel Cancer Project – Epidemiology and surgical risk in the elderly

OBJECTIVE

To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly.

METHODS

Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest.

RESULTS

Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes' stage was lower. They underwent surgery less often (81% versus 88%, p<0.001), but more frequently needed urgent or emergency procedures (p<0.001) and non-excisional surgery (7.7% versus 6.6%, p<0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p<0.001), and their median length-of-stay was 2 days longer (p<0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes' stage A and D disease, but not for other subgroups.

CONCLUSION

Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.

Rectal cancer surgery in the elderly: analysis of consecutive 158 patients with stage III rectal cancer

BACKGROUND

It is difficult to establish a clear-cut indication for rectal surgery in elderly patients because of greater risk. We tried to clarify the factors associated with the short-term and long-term outcomes between elderly and younger patients.

MATERIALS AND METHODS

We clarified the potential predictors of the cancer-related and disease-free survivals after surgery, the factors associated with the elderly, preoperative comorbid conditions, and postoperative complications in 158 patients with stage III rectal cancer who underwent surgery, including 33 elderly patients (>or=75 years) and 125 younger patients (<75 years).

RESULTS

An old age and macroscopic types 3 and 4 were independent poor prognostic factors of cancer-related survival, whereas the disease-free survival of the younger patients was not longer than for the elderly patients. Interestingly, the survival rate in the elderly patients with recurrence was shorter than that in the younger patients. Histopathological type except well differentiated and without chemotherapy were significant tumor characteristics associated with the elderly patients. On preoperative comorbid conditions, elderly patients have more cardiovascular diseases than younger patients, whereas there were no significant differences in the postoperative complications.

CONCLUSION

Strength of the adjuvant and intensive therapies after recurrence may contribute to gain long-term survival in the elderly rectal cancer patients.

The impact of surgery for colorectal cancer on quality of life and functional status in the elderly

PURPOSE

Colorectal cancer is a common diagnosis in the elderly. Frequently concerns arise about outcomes after surgery, and little is known about postoperative quality of life in this older group after major bowel surgery. The objective of this study was to compare quality of life and functional status of elderly patients (older than aged 80 years) who have undergone surgery for colorectal cancer with a younger (younger than aged 70 years), procedure-matched control group.

METHODS

Patients in the case (older than aged 80 years) and control groups (younger than aged 70 years) were identified from the colorectal cancer database at Mount Sinai Hospital, Toronto, Canada. All had treatment for colorectal cancer within the last five years. Patients were surveyed by mail using the European Organization for Research and Treatment of Cancer quality of life scales specific to cancer and colorectal cancer (EORTC-C30 and EORTC-CR38) and the Short Form-36. Student's t-test was used to test differences.

RESULTS

There were 29 patients in each of the groups. The current average ages were 83.2 (standard deviation=2.79) years, and 67.7 (standard deviation=5.1) years, respectively. The two groups scored similarly on the European Organization for Research and Treatment of Cancer quality of life scales in all domains except physical functioning, functional role, micturition, and stoma-related problems. Similarly, the mean scores of the Short Form-36 were similar with the exception of the vitality domain. Most patients did not require special assistance or alternate living arrangements after discharge from the hospital, and most patients seemed to be able to return to their preoperative level of functioning. However, stoma care was a greater concern to the elderly.

CONCLUSIONS

Elderly patients older than aged 80 years who are selected for surgery have a quality of life comparable to younger patients in most respects. Therefore, colorectal cancer surgery may be offered to the highly functioning elderly with the expectation of a good quality of life postoperatively.

Rectal cancer treatment of the elderly

OBJECTIVE

Life expectancy and incidence of rectal cancer have been increasing. The purpose of this study was to evaluate rectal cancer treatment among very old patients.

METHODS

This prospective national cohort study includes all 4875 rectal cancer patients in Norway aged over 65 years treated between November 1993 and December 2001. Patients aged 65-74, 75-79, 80-84 and over 85 years were compared for patient-, tumour- and treatment-characteristics and relative survival. Two thousand eight hundred and forty patients treated for cure with major surgery and TME technique were further evaluated for postoperative mortality, five-year local recurrence, distant metastasis and disease-free survival.

RESULTS

There were more palliative surgery and local procedures and less surgery for cure (47%vs 77%, P < 0.001) for patients over 85 years compared to younger patients. Five-year relative survival was 36% for patients aged over 85 years compared to 49% for patients 80-84 years and 60% for patients 65-74 years. Among patients treated for cure with major surgery the rate of anterior resection decreased by age (67%vs 46%, P < 0.001). Postoperative mortality increased from 3% to 8% (P < 0.001). There were no significant differences in the rates of five-year local recurrence, distant metastasis or relative survival.

CONCLUSION

Although a slight increase in postoperative mortality, major rectal cancer surgery can be performed in very old patients. These patients had similar rates of local recurrence, distant metastasis and relative survival as younger patients.

Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors

BACKGROUND AND OBJECTIVES

Geriatric population life expectancy is rapidly increasing and the impact of major surgical procedures is not well defined. The purpose of this study was to compare short term surgical results assessing mortality and morbidity and long-term survival and disease-free interval in elective rectal surgery patients older than 65 years of age. The main independent risk factors of mortality, morbidity, and overall and disease-free survival were also identified.

METHODS

Out of 177 rectal cancer accepted consecutively from 1991 to 2002, we studied the main clinical and pathological parameters comparing patients older and younger than 65 years. Data have been collected in a database and variables considered were studied by univariate analysis; independent predictive factors of 30-day mortality and morbidity were identified by multiple logistic regression analysis. Overall, cancer specific and disease-free survival curves were obtained with the Kaplan-Meier method and results compared with the log-rank test. Independent risk factors of overall and disease-free survival have been identified by multivariate logistic regression analysis.

RESULTS

In patients younger and older than 65 years postoperative mortality (3.2% vs. 9.6%) and morbidity (30% vs. 29%) were not significantly different. Variables independently associated with 30-day mortality were the duration of surgical procedures and postoperative complications. The Kaplan-Meier survival curves showed a significantly worst overall survival (P = 0.003), cancer specific survival (P = 0.02), and disease-free survival (P = 0.03) in patients aged 65 years or more. Multivariate analysis showed that pT, grading, preoperative CEA level, gender, and site of the tumor along the rectum, the number of blood transfusion and the age group of more than 65 years are independent risk factors for both overall survival and disease-free interval. The presence of residual disease was an adjunctive factor of overall survival, whereas the Astler and Coller staging was a risk factor for the disease-free survival.

CONCLUSION

The short-term prognosis for elective rectal cancer procedure in patients over 65 years of age was comparable to that of younger patients, whereas long term cancer-related survival was statistically worst in older patients.

Surgery and pre-operative irradiation for locally advanced or recurrent rectal cancer in patients over 75 years of age

OBJECTIVE

Reports of multimodal treatment regimens especially focusing on locally advanced or recurrent rectal cancer in the elderly, aged>75 years, are unavailable. We have tried to identify and evaluate pre- and peri-operative risk factors for morbidity and mortality and outcome after irradiation/surgery regimens in such patients.

PATIENTS AND METHODS

Prospective registration of 86 consecutive patients aged>75 years undergoing elective surgery after irradiation 46-50 Gy for either primary locally advanced rectal cancer (n=51) or recurrent rectal cancer (n=35) from January 1991 to August 2003, 51 men and 35 women, median age 78 years (range 75-85 years) in a national cancer hospital.

RESULTS

Multivisceral resections were needed in 63% of patients and 70% R0 resections were obtained in locally advanced cases and 46% in recurrent ones. Both in-hospital- and 30-day-mortality was 3.5%. Sixty-two postoperative complications occurred in 38 patients, three of them fatal. Both operation times over 5 h and transfusion of more than 3 SAG were prognostic factors regarding infections. Estimated five-year survival in R0 patients was 46%. Estimated five-year survival for patients with nonmetastatic tumours with locally advanced primary cancer was 29% and for locally recurrent rectal cancer 32%. Old males had a higher mortality rate the first year after surgery than females with only 65% relative survival compared to a matched normal population. The estimated five-year local recurrence rates were 24% for R0 resections and 54% for R1 resections (P=0.434 ns) and 24% and 45% for locally advanced and recurrent rectal cancer (P=0.248 ns), respectively.

CONCLUSION

Thorough pre-operative evaluation and preparation and judicious surgery are important for achieving potentially curative treatment with acceptable morbidity in locally advanced and recurrent rectal cancer in patients over 75 years of age. We suggest that these patients should be evaluated and considered for treatment by multidisciplinary teams as younger patients.

Postoperative outcome among elderly patients after general anesthesia

BACKGROUND

Preoperative decision-making for elderly patients requires a long-term perspective. The aim of this study was to identify preoperative risk factors for decreased 1- to 5-year survival rates and to compare the survival rates of stratified risk groups with those of the sex- and age-matched general population.

METHODS

Subjects were 406 patients, aged 80 years or older, who underwent surgery with general anesthesia. Higher age, male sex, dependency in daily living, low serum albumin level, malignancy, abdominal surgery, emergency surgery and high ASA class were analyzed for survival using univariate and multivariate analysis with Cox's proportional hazard model. One- to 5-year survival rates were estimated using life table analysis for patients divided by risk factors. The survival data were also compared with the cumulative survival rates of the sex- and age-matched general population.

RESULTS

Multivariate analysis identified three factors that were significantly associated with decreased survival rates: male sex, dependency in daily living and abdominal surgery. Long-term survival among patients older than 90 years was comparable to those of the general population. Although improved in recent years, overall survival rates were much lower than expected due to poor outcome among patients dependent in daily living and those who underwent abdominal surgery.

CONCLUSIONS

In patients 80 years or older who underwent surgery with general anesthesia, independent risk factors for decreased survival are male sex, dependency in daily living and abdominal surgery. Only patients independent in daily living who underwent non-abdominal surgery had survival rates comparable to those of the general population.

Age and colorectal cancer with focus on the elderly: trends in relative survival and initial treatment from a Danish population-based study

PURPOSE

Elderly patients with colorectal cancer undergo surgery with curative intent less frequently than younger patients, and survival declines with increasing age. We compared relative survival of colorectal cancer among patients older than 75 years with that of younger patients in Denmark during the period 1977 to 1999. We also examined trends in choice of initial treatment.

METHODS

From the files of the nationwide population-based Danish Cancer Registry, we identified all cases of colorectal cancer diagnosed between 1977 and 1999. We then linked this data to information on survival obtained from the Danish Register of Causes of Death and from the Central Population Register.

RESULTS

During the entire study period, short-term and long-term relative survival improved for patients of all ages, but the improvement was more pronounced among elderly patients (>75 years). Radical resection was increasingly chosen as the initial treatment for elderly patients; during the 1995 to 1999 period it was performed on approximately 50 percent of such patients, almost as frequently as among younger patients.

CONCLUSIONS

Relative survival of elderly colorectal cancer patients (>75 years) improved in Denmark between 1977 and 1999. In the most recent period studied, 1995 to 1997, only minor differences in five-year relative survival were observed among younger, middle-aged, and elderly patients. A simultaneous increase in the rate of radical resection among elderly patients, reflecting more effective treatment, may underlie this finding.

Curative resection of T1 colorectal carcinoma: risk of lymph node metastasis and long-term prognosis

PURPOSE

The features of T1 colorectal adenocarcinoma and the risk determination of lymph node metastasis were reviewed. Prognostic factors were assessed to verify whether the risk of lymph node metastasis would influence the long-term prognosis.

METHODS

Patients undergoing curative resection of T1 colorectal adenocarcinoma at the Taipei Veterans General Hospital from December 1969 to August 2002 were retrospectively studied. Patients with synchronous colorectal cancer, distant metastasis, familiar adenomatous polyposis, or inflammatory bowel disease were excluded. The associations between lymph node metastasis and clinicopathologic variables were evaluated univariately using chi-squared test, Fisher's exact test, or Student's t -test, and multivariately using logistic regression. Univariate analysis by the log-rank test and multivariate analysis by Cox regression hazards model determined the factors influencing the overall survival.

RESULTS

A total of 159 patients were included. Sixteen patients (10.1 percent) had lymph node metastasis. The risk of lymph node metastasis included histologic grade (P = 0.005), lymphatic vessel invasion (P = 0.023), inflammation around cancer (P = 0.049), and budding at the invasive front of tumor (P = 0.022). Age (P = 0.001) and number of total sampling lymph nodes (P < 0.0001) were found to be the factors influencing the overall survival.

CONCLUSIONS

Variables that predict lymph node metastasis in surgically resected T1 colorectal carcinoma may not impact the long-term prognosis.

The management of rectal cancer in the elderly

INTRODUCTION

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies.

METHODS

A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference.

CONCLUSION

Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Colorectal cancer in geriatric patients: Endoscopic diagnosis and surgical treatment

AIM: To investigate the prevalence of colorectal cancer in geriatric patients undergoing endoscopy and to analyze their outcome.

METHODS: All consecutive patients older than 80 years who underwent lower gastrointestinal endoscopy between January 1995 and December 2002 at our institution were included. Patients with endoscopic diagnosis of colorectal cancer were evaluated with respect to indication, localization and stage of cancer, therapeutic consequences, and survival.

RESULTS: Colorectal cancer was diagnosed in 88 patients (6% of all endoscopies, 55 women and 33 men, mean age 85.2 years). Frequent indications were lower gastrointestinal bleeding (25%), anemia (24%) or sonographic suspicion of tumor (10%). Localization of cancer was predominantly the sigmoid colon (27%), the rectum (26%), and the ascending colon (20%). Stage Dukes A was rare (1%), but Dukes D was diagnosed in 22% of cases. Curative surgery was performed in 54 patients (61.4%), in the remaining 34 patients (38.6%) surgical treatment was not feasible due to malnutrition and asthenia or cardiopulmonary comorbidity (15 patients), distant metastases (11 patients) or refusal of operation (8 patients). Patients undergoing surgery had a very low in-hospital mortality rate (2%). Operated patients had a one-year and three-year survival rate of 88% and 49%, and the survival rates for non-operated patients amounted to 46% and 13% respectively.

CONCLUSION: Nearly two-thirds of 88 geriatric patients with endoscopic diagnosis of colorectal cancer underwent successful surgery at a very low perioperative mortality rate, resulting in significantly higher survival rates. Hence, the clinical relevance of lower gastrointestinal endoscopy and oncologic surgery in geriatric patients is demonstrated.

Alimentary tract surgery in the nonagenarian: elective vs. emergent operations

The objective of this study was to compare elective with emergent surgery in patients over the age of 90 years. We retrospectively reviewed the records of patients over 90 years of age who underwent alimentary tract surgery between 1994 and 2002 at a community teaching hospital. Of 100 patients (mean age 92 years; range 90 to 98 years), 82 were women and 18 were men. Seventy-three percent were admitted from private homes or assisted-living facilities, and 27% came from a skilled-nursing facility (SNF). Major comorbid conditions existed in 93%. Procedures included right hemicolectomy (22%), adhesiolysis and/or small bowel resection (19%), cholecystectomy (14%), left-sided or sigmoid colectomy (11%), and perineal proctectomy (8%). Overall morbidity and mortality were 36% and 15%, respectively. Postoperative complications included respiratory failure and pneumonia (11%), arrhythmias (9%), delirium (7%), congestive heart failure and myocardial infarction (6%), and urinary complications (4%). Twenty-eight percent of the operations were elective, and 72% were emergent. Morbidity and mortality were higher in the emergent group (41% and 19%, respectively) than in the elective group (26% and 4%, respectively; P=0.04), especially for patients with an emergent surgical problem who came from a nursing home (22%). Average length of stay was 12 +/- 10 days (range 2 to 69 days) with little difference between elective and emergent cases. Sixty-four percent of patients were discharged to skilled-nursing facilities. Alimentary tract surgery can be performed safely in nonagenarians, and they should not be denied surgical care solely because of age.

Should patients over 85 years old be operated on for colorectal cancer?

BACKGROUND

The aim of this study is to evaluate risk factors for mortality, morbidity, and long-term survival in very old patients with colorectal cancer compared with old patients.

METHODS

Patients operated on with colorectal cancer aged 75 years old or older were divided into 2 groups: Group A (75-84 years, n = 93) and Group B (>or=85, n = 21).

RESULTS

The serum albumin level, oxygen pressure in arterial blood gases, and forced expiratory volume in 1 second in Group B were significantly lower than in Group A, respectively (P = 0.0094, 0.0264, 0.0363). Pulmonary complications were developed significantly more frequently in Group B than in Group A (P = 0.0019). Group B had a significantly higher mortality rate than Group A (P = 0.0477). There was no significant difference between the 2 groups in the 2- and 5-year survival rates.

CONCLUSIONS

Very old patients with colorectal cancer should not be denied surgery on account of chronological age alone, although the perioperative risks for the very old are very high.

Management of Colorectal Cancer in Elderly Patients

The treatment of colorectal cancer has evolved dramatically over the last 15 years. Advances in surgery, radiotherapy and chemotherapy have enabled oncologists to cure more patients and offer improved quality of life to patients not amenable to cure. Specific knowledge of colorectal cancer care of the elderly, while lagging behind the treatment of younger patients, is beginning to emerge. Informed by recent trials, the approach towards elderly patients is shifting towards more aggressive treatment and multimodal therapy. Surgeons are operating on the elderly with greater frequency, less operative mortality and greater success; 5-year survival following potentially curative surgery has risen from 50% to 67%.Research of adjunctive therapy for colorectal cancer is enrolling more elderly patients, and with this has come an understanding of the role of chemotherapeutic agents in the treatment of the elderly, used individually and within multi-drug regimens. This research offers insight into how the elderly respond to chemotherapy, informing clinicians on anticipated benefits and toxicities of treatment. Fluorouracil-based regimens, which have long been the standard adjuvant chemotherapy, have been shown to offer benefits to the elderly compared with those not receiving adjuvant chemotherapy (71% versus 64% 5-year survival), and to cause similar toxicities as seen in younger patients. The role of novel chemotherapeutic agents in the treatment of elderly patients with colorectal cancer is also emerging, with studies finding that irinotecan, in combination with a fluorouracil-based regimen, can offer a further survival benefit of over 2 months compared with fluorouracil alone. While newer agents such as capecitabine, oxaliplatin, raltitrexed and tegafur/uracil (UFT) have been focused upon by clinical researchers, data on their use in the elderly remain unconvincing. Not only are we approaching a clearer understanding of the effectiveness of cancer care among the elderly, but research is also beginning to identify the cost effectiveness of both standard and emerging chemotherapeutic agents. Cost effectiveness of fluorouracil-based regimens, depending on delivery strategy, use of modulating agents and stage of cancer vary from US dollars 2000 per quality-adjusted life-year (QALY) to US dollars 20200 per QALY (1992 values). Irinotecan therapy has not been fully investigated from the perspective of cost effectiveness; the figure of US dollars 10000 per QALY (1998 values) for irinotecan monotherapy over fluorouracil regimens is likely an underestimate, while cost analysis of irinotecan and fluorouracil combination therapy has not yet been reported. Our understanding of cost effectiveness of other novel agents has lagged behind; further research on these agents is needed. Nonetheless, as the effects of these novel agents upon both outcomes and costs continue to be defined, both curative and palliative treatment of colorectal cancer in the elderly patient will become more sophisticated and effective.

Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival

OBJECTIVE

To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors.

DESIGN

Prospective cohort.

SETTING

The former Wessex Health Region, South West England.

PARTICIPANTS

All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419).

OUTCOMES

Death from colorectal cancer and all cause over five year follow up from initial diagnosis.

MAIN RESULTS

Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent.

CONCLUSIONS

Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.

Is there ageism in oncology?

OBJECTIVE

To use routine data to explore age-related decision making in the hospital management of colorectal cancer.

DESIGN

Retrospective analysis of linked Scottish cancer registry and hospital discharge data for colorectal cancer.

SETTING

All Scottish general hospitals.

PARTICIPANTS

All patients on the Scottish colorectal cancer registry 1992-6 (n = 15,299).

MAIN RESULTS

Histological verification was used to indicate the "gold standard" of investigation. Definitive surgery and chemotherapy were used as indicators of treatment received. After adjusting for demographic factors, tumour sub-site, co-morbidity and route of first admission, increasing age was associated with markedly decreased rates of histological verification, surgery and chemotherapy. It is still not possible to be sure whether there is ageism in the management of older patients with colorectal cancer. However, the rate of histological verification fell markedly with increasing age, making it questionable whether decisions to treat were based on best clinical practice at the time. Differences observed between this study and clinical trial data may represent the margin of ageism between everyday clinical practice and controlled conditions.

CONCLUSIONS

The value of this analysis lies in the fact that the data come from routine clinical practice rather than special studies. The improved content of Scottish cancer register and the ability to link it to hospital care provides a useful baseline for monitoring adherence to clinical guidelines.

Rectal cancer surgery in patients more than 80 years of age

BACKGROUND

This retrospective study aimed to compare the prognosis for rectal cancer in patients more than 80 years old with that observed in younger patients.

METHODS

Patients operated on for a rectal adenocarcinoma, from 1980 to 1998, were divided into two groups: group 1 (>80 years, n = 92); group 2 (<80 years, n = 276).

RESULTS

There were significant differences between the two groups with regard to the sex ratio, the American Society of Anesthesiologists (ASA) classification, the emergency presentation, and the curative operation rate. The operative mortality rate was 8% in group 1, 4% in group 2 (P = 0.26). The overall 5-year survival rate was 35% in group 1, 53% in group 2 (P = 0.0004). In patients operated on for cure, the cancer-specific 5-year survival rate was 50% in group 1, 59% in group 2 (P = 0.08).

CONCLUSIONS

The prognosis for rectal cancer in patients over 80 years is not significantly different from that of younger patients. Surgery should not be restricted on the basis of age.

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older

PURPOSE

Because the elderly population in Western countries is rapidly increasing, as is their life expectancy, studies aimed at determining the impact of major surgery for primary rectal cancer in this group are warranted. The purpose of this study was to compare perioperative morbidity and mortality and long-term disease-specific and overall survival in primary rectal cancer patients, older and younger than 75 years of age, subject to major pelvic surgery.

METHODS

From September 1986 to December 1996, the Prospective Colorectal Service Database identified 1,120 consecutive patients who underwent major pelvic surgery for primary rectal cancer. Of these, 157 (15 percent) were 75 years of age or older and comprise the elderly group. From the remaining 963 patients younger than 75 years of age, a representative random sample of 174 was selected and constitutes the younger group. Data were obtained from computerized databases and confirmed via chart review and telephone interviews.

RESULTS

Perioperative complications were observed in 53 (34 percent) elderly and 63 (36 percent; P = not significant) younger patients. Perioperative deaths occurred in two (1.3 percent) elderly and one (0.6 percent; P = not significant) younger patient. The median follow-up time was 48 months. Although the overall survival was lower in the elderly group (P = 0.02; the 5-year overall survival rates were 51 and 66 percent), the disease-specific survival rate was similar in the two groups (P = 0.75; the 5-year disease-specific survival rates were 69 and 71 percent).

CONCLUSION

In select individuals 75 years of age or older, major pelvic surgery for primary rectal cancer can be done with perioperative morbidity and mortality rates comparable to those obtained in younger individuals, while achieving excellent disease-specific and overall long-term survival.

Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group

BACKGROUND

The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients.

METHODS

We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65-74 years, 75-84 years, and 85+ years were expressed in relation to those aged less than 65 years.

FINDINGS

From 28 independent studies, and a total of 34,194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking.

INTERPRETATION

The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

Treatment of colorectal cancer in patients aged over 75

Colorectal cancer is a common malignancy which is occurring with increasing incidence in the elderly. As the age of the population increases so the importance of this malignancy will gradually increase. In addition a high proportion of elderly patients present with intestinal obstruction secondary to colorectal cancer and therefore the management of intestinal obstruction in the elderly becomes an important surgical consideration. This review discusses the management of colorectal cancer in patients over the age of 75 in both the elective and emergency situations with particular reference to screening, surgical management and the use of adjuvant therapy.

Surgery for local recurrence or distant metastases in patients aged 75 years or older

Between 1982 and 1997, a total of 105 patients aged 75 years or older (median age 78 years) underwent surgical treatment for recurrent solid tumours. The most frequent primary tumours were melanoma, colorectal carcinoma and breast cancer. Sixty-one patients had complete removal of recurrent tumour. Post-operative mortality was 3.8% (four of 105 patients). The median hospital stay was 16 days and the post-operative hospital stay was 10 days. At a median follow-up of 57 months, 77 patients had died. Twenty one patients died of causes unrelated to the tumour. The overall survival of 105 patients was 35% at 3 years and 27% at 5 years. Following R0 resection, 5-year survival was 43%, (n = 61) and in the absence of post-operative complications even reached 50% (n = 47). Survival correlated with completeness of tumour resection (P<0.0001) and post-operative complications (P=0.021). No significant correlation could be established between survival and age, ASA score, blood replacement, primary tumour location or sex. Elderly patients presenting with recurrent tumour should be evaluated for surgical resection. If tumour removal is complete and post-operative complications are avoided, a 5-year survival rate of over 40% may be expected.