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

Elective colorectal cancer surgery in nonagenarians and postoperative outcomes

OBJECTIVES

The population of very elderly patients is increasing, and nonagenarians have significantly higher mortality rates and poorer rates of survival than younger patients. Meanwhile, recent studies have shown colorectal cancer surgery in nonagenarian patients to be feasible regarding postoperative outcomes. This retrospective study aims to evaluate the postoperative outcomes of nonagenarians in the latest clinical settings.

METHODS

Consecutive nonagenarian patients who underwent elective colorectal cancer surgery between 2018 and 2020 retrospectively enrolled (Trial registration number: UMIN000046296 on December 7th, 2021). Clinicopathological data and short-term postoperative outcomes were collected for statistical analysis.

RESULTS

This study included 81 nonagenarian patients (31 males, 50 females). Postoperative complications occurred in 21 patients (25.9%), and 3 patients died within 90 days (3.7%). Multivariate analysis revealed prognostic nutritional index was a significant predictor of postoperative complications (OR 2.99, 95% CI 0.78-9.10, P = 0.048), and performance status ≥ 3 could be an independent risk factor of 90-day mortality (HR 32.30, 95% CI 3.20-326.10, P = 0.032).

CONCLUSIONS

Short-term outcomes after surgical treatment for nonagenarian patients with colorectal cancer were acceptable. Low prognostic nutritional index was closely related to postoperative complications and poor performance status could also lead to 90-day mortality. In aging populations, risk stratification to prevent poorer postoperative outcomes in nonagenarian patients is needed.

Factors affecting the post-operative outcomes in patients aged over 80 following colorectal cancer surgery

PURPOSE

In 2019, in Australia, there were 500,000 people aged 85 and over. Traditionally, clinicians have adopted the view that surgery is not desirable in this cohort due to increasing perioperative risk, perceived minimal clinical benefit, and shortened life expectancy. This cohort study is aimed at investigating postoperative outcomes from elective and non-elective colorectal cancer surgery in patients aged 80 and over.

METHODS

A retrospective analysis was conducted on patients from 2010 to 2020 on a prospectively maintained colorectal database. Patients aged over 80 who underwent surgical resection for colorectal cancer were reviewed. Oncological characteristics, short-term outcomes, overall survival, and relapse-free survival rates were analysed.

RESULTS

A total of 832 patients were identified from the database. Females comprised 55% of patients aged 80 and above. The median age was 84 for octogenarians and 92 for nonagenarians. Most patients were ASA 2 (212) or ASA 3 (501). ASA 3 and 4 and stage III pathology were associated with higher postoperative complications. Fifty percent of over 80 s and 37% of over 90 s were surgically discharged to their own home. Overall survival at 30, 180, and 360 days and 5 years was 98.1%, 93.1%, 87.2%, and 57.2% for the over 80 s and 98.1%, 88.9%, 74.9%, and 24.4% for the over 90 s.

CONCLUSION

Our results demonstrate that surgical treatment of older patients is safe with acceptable short-, medium-, and long-term survival. Nonetheless, efforts are needed to reduce the rates of complications in older patients, including utilisation of multi-disciplinary teams to assess the optimal treatment strategy and postoperative care.

A new stoma for an older person-An association with quality of life and physical function: A systematic review

BACKGROUND

Older people are more likely to have a stoma postabdominal surgery than younger people. Few studies have examined the effect of a stoma on older people. The aim of this review was to explore the effect of a stoma on functional independence of an older person. We explored secondary outcomes of poststoma formation length of hospital stay, quality of life and factors affecting stroma independence.

METHODS

An exploratory systematic review was developed by our multidisciplinary group including an expert patient, colorectal surgeon, stoma nurse, physiotherapist, geriatrician, and methodologist. Four databases were searched including studies with participants 60 years old or older, who had undergone abdominal surgery for any pathology resulting in an abdominal stoma.

RESULTS

We identified 857 studies, of which we included 25 in the final review incorporating 6972 participants (average age 67.4 years). There was a strong association between presence of stoma and (1) worse physical function (standardized MD = 0.7; 95% CI 0.21-1.19; I²  = 95) and (2) worse quality of life (standardized MD = 1.61; 95% CI 0.5-2.72, I²  = 98). The same effect was seen in fecal ostomy and urinary diversion. Few studies measured stoma independence and only one examined factors affecting this. No studies examined length of stay.

CONCLUSIONS

Stoma have a negative association with the physical function and quality of life of older people. Future studies should focus on identifying modifiable factors that may affect physical function, quality of life, and stoma independence.

What is related to postoperative outcome of frail status in elective colorectal cancer surgery?

Background

The population affected by colorectal cancer is growing, and there is an increasing need for prevention of functional decline following treatment. We proposed that the Kihon Checklist published by the Japanese Ministry of Health, Labor, and Welfare would be an appropriate means of frailty assessment for prediction of postoperative complications in older patients with colorectal cancer. This prospective cohort study aims to identify the factors influencing postoperative frailty.

Methods

We prospectively enrolled consecutive patients with colorectal cancer and aged ≥ 65 year (N = 500) between May 2017 and December 2018. Eligible patients were assessed with the Kihon Checklist prior to surgery and 30 days after surgery. The main measures were variables related to postoperative change in view of frail status.

Results

According to the Kihon Checklist questionnaire, 164 patients were frail preoperatively and 172 patients were frail postoperatively, whereas 38 patients changed from "nonfrail" before surgery to postoperative "frail." Overall complications were counted in 97 patients (19.4%), and 5 patients died. Performance status ≥ 2, history of laparotomy, open surgery, complication, ostomy creation, and delirium were significantly associated with changing postoperative "frail" (P = .014, P = .023, P = .006, P < .001, P = .023, and P = .024, respectively). In multivariate analysis, independent related factors of changing postoperative "frail" were complication (odds ratio 2.69, 95% confidence interval 1.19–6.09, P = .018) and ostomy creation (odds ratio 2.32, 95% confidence interval 1.01–5.33, P = .047).

Conclusion

The Kihon Checklist questionnaire could identify the factors related to postoperative change of frailty status in older patients with colorectal cancer. This cohort concluded that whether postoperative complication occurred or not was closely associated with perioperative change of frailty status.

•

Our prospective cohort study examined the factor influencing postoperative frailty in older patients with colorectal cancer by Kihon Checklist questionnaire.

•

The importance of this study is that postoperative complication and ostomy creation were significantly associated with postoperative change of frailty status.

Quality of life preferences in colorectal cancer patients aged 80 and over

BACKGROUND

Management of patients with colorectal cancer (CRC) is about not only survival, but also quality of life (QoL). What patients want is important but is not well researched or understood for elderly patients where it is very relevant. This study aimed to measure and compare what patients with CRC aged 80 and over and surgeons consider important in terms of survivorship after surgery for CRC.

METHODS

Patients aged 80 and over who were having surgery for CRC were recruited and interviewed using closed and open questions about their expectations of surgery and various QoL dimensions. These were assessed preoperatively and 3 months post-operatively. Surgeons ranked the same QoL dimensions of patients by questionnaire.

RESULTS

Nineteen patients (median age 87.5, range 80-95, eight males and 11 females) were recruited. Patients rated items relating to health, mobility and independence (n = 23) as top three items most often followed by people outside self (n = 13). Surgeons underestimated importance in 17 domains with the biggest discrepancy being in 'avoiding a stoma' (4.11 versus 2.3, P < 0.01).

CONCLUSION

With patients over 80 years having surgery for CRC, there is a lack of concordance between what surgeons think is important and what patients think is important. Despite this, CRC patients aged 80 and older are almost always satisfied with the outcome of surgery. Surgeons should ensure that they understand patients' expectations and that they are aligned with likely outcomes of surgery.

Surgical outcomes following colorectal cancer resections in patients aged 80 years and over: results from the Australia and New Zealand Binational Colorectal Cancer Audit

AIM

The primary aim was to compare the 30-day morbidity and mortality in patients aged ≥80 years undergoing surgery for colorectal cancer with those aged <80 years. The secondary aim was to identify independent outcome predictors.

METHOD

This was a retrospective study of patients undergoing surgery for colorectal cancer between January 2007 and February 2018. Patients were divided into those <80 years and those ≥80 years at the time of surgery. Data had been collected prospectively by the Australasian Binational Colorectal Cancer Audit and included patient demographics, site and stage of tumour, comorbidity, operative details, American Society of Anesthesiologists score (ASA), pathological staging, 30-day mortality and morbidity (medical and surgical). Univariate and multivariate analyses were used to identify predictors of 30-day morbidity and mortality.

RESULTS

During the study period, 4600 out of 20 463 (22.5%) patients were ≥80 years. They had a greater 30-day mortality after both colonic (97/2975 [3.3%] vs. 66/7010 [0.9%], P < 0.001) and rectal resections (50/1625 [3.1%] vs. 36/9006 [0.4%], P < 0.001) compared with younger patients. They also had an increased length of stay (colon cancer, 9 vs. 7 days; rectal cancer, 10 vs. 8 days; P < 0.001) and medical complications (colon cancer, 23.5% vs. 12.7%; rectal cancer, 25.2% vs. 11.2%; P < 0.001). Surgical complications were equivalent. Age ≥80 years was not an independent predictor of 30-day morbidity or mortality. Patients ≥80 years who were ASA 2/3 and had rectal cancer seemed to fare worse in terms of 30-day mortality (ASA 2, 22%, 95% CI 9%-36%, P < 0.001; ASA 3, 11%, 95% CI 4%-19%, P< 0.001).

CONCLUSIONS

Postoperative morbidity and mortality are significantly greater in patients ≥80 years undergoing colorectal cancer surgery. Any recommendation for surgery in this age group should take into account patient comorbidity and not be based on age alone.

Quality of life assessment in the late postoperative period of patients with rectal cancer submitted to total mesorectal excision

After the introduction of total mesorectal excision (TME) and radiochemotherapy, excellent results have been achieved in the treatment of patients with rectal cancer. With better oncologic control of the disease, the functional results of this type of therapeutic approach and their impact on the quality of life (QOL) of patients started to be increasingly valued. The aims of this study were to evaluate the QOL of patients with rectal cancer submitted to TME in the late postoperative period and the possible factors that directly influence their quality of life. A total of 72 patients submitted to TME due to extraperitoneal rectal tumor were assessed, after at least one postoperative year, by applying QOL questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38), in addition to a specific clinical questionnaire and rectal examination. Patients were evaluated regarding gender, age, indication of radiotherapy and chemotherapy preoperatively, length of postoperative period, distance from the anastomosis to the anal verge and general health status. The mean overall health status of patients was satisfactory (82.06). There was no difference in overall health status between patients with respect to gender, but the male patients had less insomnia (p = 0.002), better future prospects (p = 0.011), fewer effects of chemotherapy (p = 0.020) and better sexual function (p < 0.0001). Patients younger than 50 years had fewer urinary problems (p = 0.035), whereas those older than 65 years reported poorer sexual function (p = 0.012). Patients who underwent neoadjuvant therapy had more diarrhea (p = 0.012). Quality of life did not change significantly with time after surgery and the distance from the anastomosis to the anal verge. We conclude that patients undergoing TME have a good quality of life one year after the surgery and that the factors capable of affecting QOL should be identified and improved.

Sociodemographic predictors of surgery refusal in patients with stage I-III colon cancer

BACKGROUND AND OBJECTIVES

Over 104 000 cases of colon cancer are estimated to be diagnosed in 2020. Surgical resection is a critical part of colon cancer treatment and adequate resection impacts prognosis. However, some patients refuse potentially curative surgery. We aimed to identify the rate and predictors of surgery refusal among patients with colon cancer.

METHODS

The National Cancer Database (2004-2015) was queried for patients diagnosed with stage I-III colonic adenocarcinoma. Sociodemographic factors, clinical features, and treatment facility characteristics were collected. Patients who underwent surgery with curative intent were compared to those who refused surgery. Multivariable analysis was used to identify factors associated with surgery refusal. Adjusted survival analysis was performed on propensity-matched cohorts.

RESULTS

A total of 151 020 patients were included and 1071 (0.71%) refused surgery. In multivariable analysis older age, Black race, higher Charlson comorbidity score, Medicaid, Medicare, or lack of insurance were predictive of refusing surgery. After propensity matching, there was a significant difference in 5-year survival for patients who refused surgery vs those who underwent surgery (P < .001).

CONCLUSIONS

There are racial and socioeconomic disparities in the refusal of surgery for colon cancer. Further studies are needed to better understand the drivers behind differences in refusing curative surgery for colon cancer.

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.

Bowel dysfunction after sigmoid resection for cancer and its impact on quality of life

BACKGROUND

Several studies have explored functional outcomes after rectal cancer surgery, but bowel dysfunction after sigmoid resection for cancer has hardly been considered. The aim of this study was to identify the prevalence and pattern of bowel dysfunction after resection for sigmoid cancer, and the impact of bowel function on quality of life (QoL) by comparison with patients who had polypectomy for cancer.

METHODS

This was a national cross-sectional study. Data were collected from the Danish Colorectal Cancer Group database, and a questionnaire regarding bowel function and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL questionnaire was sent to all Danish colonic cancer survivors treated with sigmoid resection or polypectomy between 2001 and 2014.

RESULTS

A total of 3295 patients (3061 sigmoid resection, 234 polypectomy) responded to the questionnaire (response rate 63·8 per cent). Twelve bowel symptoms were more prevalent after sigmoid resection, including: excessive straining, fragmentation, bloating, nocturnal defaecation, bowel false alarm, liquid stool incontinence, incomplete evacuation and sense of outlet obstruction. QoL impairment owing to bowel symptoms was reported in 16·6 per cent of patients in the resection group and 10·1 per cent after polypectomy (P = 0·008). Obstructed defaecation symptoms (ODS) were encountered significantly more often after sigmoid resection than following polypectomy (17·9 versus 7·3 per cent; P < 0·001). In the resection group, patients with ODS had substantial impairment on most aspects of QoL assessed by the EORTC QLQ-C30.

CONCLUSION

Sigmoid resection for cancer is associated with an increased risk of long-term bowel dysfunction; obstructed defaecation is prevalent and associated with substantial impairment of QoL.

The risk of long-term bowel dysfunction after resection for sigmoid adenocarcinoma: a cross-sectional survey comparing complete mesocolic excision with conventional surgery

AIM

To investigate whether complete mesocolic excision (CME) might carry a higher risk of bowel dysfunction and subsequent reduction in quality of life compared with conventional resection.

METHOD

A cross-sectional questionnaire study based on data from a national survey regarding long-term bowel function and a population-based cohort study comparing CME (study group) with conventional resection (control group). A total of 622 patients undergoing elective resection for Stage I-III sigmoid adenocarcinoma at four university colorectal centres between June 2008 and December 2014 were eligible to receive the questionnaire in mid-November 2015. Primary outcomes were four or more bowel movements daily, nocturnal bowel movements, unproductive call to stool, obstructive sensation and impact of bowel function on quality of life (QOL).

RESULTS

One hundred and twenty-seven (69.0%) and 289 (66.0%) patients in the study and control groups, respectively, responded to the questionnaire after medians of 4.41 [interquartile range (IQR) 2.50, 5.83] and 4.57 (IQR 3.15, 5.82) years, respectively (P = 0.048). CME was not associated with: increased risk of four or more bowel movements daily [adjusted OR 1.14 (95% CI 0.59-2.14; P = 0.68)], nocturnal bowel movements [adjusted OR 1.31 (0.66-2.53; P = 0.43)], unproductive call to stool [adjusted OR 0.99 (0.54-1.77; P = 0.97)] or obstructive sensation [adjusted OR 1.01 (0.56-1.78; P = 0.96)]. While one in five patients in both groups had moderate to severe impact of bowel function on QOL, there was no association with CME.

CONCLUSION

For patients with sigmoid cancer, CME is associated with neither higher risk of bowel dysfunction nor impaired QOL.

Clinical outcomes after varicose vein procedures in octogenarians within the Vascular Quality Initiative Varicose Vein Registry

BACKGROUND

Whereas chronic venous insufficiency and varicose veins (VVs) are a universally recognized problem, they are frequently underappreciated as major contributors to long-term morbidity in the elderly despite the increasing prevalence with age. Previous studies have demonstrated that chronic venous insufficiency and VV treatments in patients ≥65 years old yield an overall benefit; however, there have been few data as to whether octogenarians are undergoing these procedures and with what success. As such, our objectives were to investigate the procedures selected, to examine clinical outcomes after VV procedures in elderly patients ≥80 years old, and to explore complication rates (both systemic and leg specific) after VV procedures in patients ≥80 years old.

METHODS

We performed a retrospective review using the Vascular Quality Initiative Varicose Vein Registry of all VV procedures performed for ≥C2 disease from January 2015 to February 2017. We divided all procedures into three age groups: patients <65 years, patients ≥65 to 79 years, and patients ≥80 years. Statistical testing included χ² test for categorical variables and Student t-test for continuous variables. Two comparisons were performed: first, comparing patients <65 years old with patients ≥65 to 79 years old; and second, comparing patients ≥65 to 79 years old with patients ≥80 years old.

RESULTS

There were a total of 12,262 procedures performed, with 8608 procedures in the patients <65 years, 3226 in patients 65 to 79 years, and 428 procedures in patients ≥80 years. A total of 22,050 veins were treated during the 12,262 procedures. Almost half of procedures (46.51%; n = 5703) had only one vein treated during a single procedure. Between age groups, the percentage of one vein treated increased as the patient's age increased, ranging from 45.39% (n = 3875) for patients <65 years to 48.55% (n = 1555) for patients between 65 and 79 years and 64.08% (n = 273) for patients ≥80 years. Patients in the group ≥80 years had an overall lower average body mass index and were more likely to be receiving anticoagulation and to undergo truncal procedures alone compared with the other groups. The group ≥80 years had a significant improvement in both Venous Clinical Severity Score (4.37 ± 4.16; P < .001) and patient-reported outcomes (8.79 ± 7.27; P < .001) from before to after the procedure. Overall complications were low in all age groups. The octogenarians had no higher risk of systemic complications.

CONCLUSIONS

Vascular specialists are performing VV procedures in octogenarians and are more likely to perform truncal only therapy. In addition, octogenarians have statistically significant improvement of Venous Clinical Severity Score and patient-reported outcomes with a low risk of complications despite more advanced venous disease at presentation.

[Psychological impact of ostomy on the quality of life of colorectal cancer patients: Role of body image, self-esteem and anxiety]

Surgery accounts for an important part of the therapeutic arsenal of colorectal cancer treatment. In digestive cancers, ostomy devices induce the loss of anal function and control. This medical appliance generates changes affecting all aspects of patients' lives. This study explores, on the one hand, the psychological impact of colostomy on colorectal cancer patients' quality of life and on the other hand, it analyzes the correlational links between body image, self-esteem and anxiety during the stoma. Thirty-five patients with colorectal cancer participated in the study, divided into 2 subgroups: 23 were carriers of a definitive stoma and the 12 others with a temporary stoma. All completed the Functional Assessment Cancer Therapy (FACT-C), the Body Image Scale (BIS), the State Trait Anxiety Inventory (STAI-Y) and the Self Esteem Scale (ETES). Analysis revealed the quality of life of temporary ostomates is more affected than that of the definitive ones. All three of them, body image, self-esteem and anxiety negatively affect the quality of life regardless of the type of stoma. This study highlights the prevalence of physical self-esteem for temporary ostomy; the role of a good body image and substantial emotional self-esteem for the permanent ostomy. Future studies are required to explore the underlying causes of the acceptance of this equipment and the mediating role of care devices.

A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia

AIM

Our aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy.

METHODS

Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess 'early' bowel function. Patients who underwent surgery 2 to 4 years previously were recruited for assessment of 'intermediate' bowel function. Healthy relatives were recruited as controls. The Memorial Sloan-Kettering Cancer Centre and EQ-5D questionnaires were used to assess bowel function and QOL, respectively. Statistical assessment included regression analyses, parametric and non-parametric tests. The association between QOL and Memorial Sloan-Kettering Cancer Centre (MSKCC) scores was evaluated using Spearman's rank correlation.

RESULTS

Ninety-one patients were recruited for assessment of 'early' and 85 for 'intermediate' bowel function. There were 85 controls. Patients had a significantly higher number of bowel movements at each follow-up (p < 0.001). At 12 months after surgery, patients reported difficulty with gas-stool discrimination. The 'intermediate' group were found to have lower scores for flatus control (<0.001) and total frequency score (p 0.03), indicating worse function. Patients with higher total MSKCC scores, no symptoms of urgency and those able to control flatus reported better QOL (p 0.006, 0.007 and 0.005, respectively) at 6 and 12 months. Gas-stool differentiation and complete evacuation correlated with better QOL in the 'intermediate' bowel function group (p 0.02 and 0.02, respectively).

CONCLUSION

Colonic resection adversely affects elements of bowel function up to 4 years after surgery. Good colonic function, represented by higher MSKCC scores, correlates with better QOL.

Clinical features of colorectal cancer patients in advanced age: a population-based approach

In the immediate future, the number of geriatric patients will continue to rise; consequently we should expect an increase of colorectal cancer, a disease of the elderly population. Through the data of a Cancer Registry, we examined (a) the effect of ageing on the main features of colorectal cancer; (b) changes in management, especially for individuals older than 80 years; and (c) changes in prognosis and survival in subgroups of patients with different age. The Registry provided information on colorectal cancer up to 2010 (27 years). A total of 5293 patients were registered; these were divided into three groups: A (0-64 years), B (65-79) and C (80 or more). Three periods of observation were chosen: 1 (1984-1992), 2 (1993-2001) and 3 (2001-2010). Group A included 1571 patients (29 %), Group B 2539 (48 %) and Group C 1183 (22.3 %). The fraction of old individuals increased during the 27 years of the investigation. In these patients, tumours were predominantly localized to the right colon (42.6 %). The rate of surgery and ratio between curative and palliative approaches were similar among the three groups (p < 0.38). There was disparity (p < 0.002) in the administration of chemotherapy (5.8 % of the elderly vs 34.4 % in remaining patients). Survival increased over time in all three groups. In the elderly, average 5-year survival was 31 % in period 1 and 55 % in period 3. These data show that in Western countries, the standard of care for colorectal cancer diagnosed in geriatric patients has improved over the last 30 years.

Changes in gastrointestinal cancer resection rates

Background

Many developments in medicine are likely to have influenced the treatment of gastrointestinal cancer, including rates of resection. This study sought to investigate changes in surgical resection rates over time among patients with gastrointestinal cancer.

Methods

Patients diagnosed between 1995 and 2012 in the Eindhoven Cancer Registry area were included. Multivariable logistic regression analysis was used to determine the independent influence of interval of diagnosis on the likelihood of having a resection.

Results

Among 43 370 patients, crude resection rates decreased between 1995 and 2012 for gastric, colonic and rectal cancer, most notably for patients aged at least 85 years with gastric cancer (from 37·3 to 13·3 per cent), and patients aged 75–84 years and 85 years or more with rectal cancer (from 80·5 to 64·4 per cent, and from 58·9 to 36·0 per cent respectively). After adjustment for patient and tumour characteristics, patients diagnosed between 2008 and 2012 with gastric (odds ratio (OR) 0·71, 95 per cent c.i. 0·55 to 0·92), colonic (OR 0·52, 0·44 to 0·62), rectal (OR 0·39, 0·33 to 0·48) and periampullary (OR 0·42, 0·27 to 0·66) cancers were less likely to undergo resection than those diagnosed between 1995 and 1998. Patients diagnosed with pancreatic cancer were more likely to undergo resection in recent periods (OR 4·13, 2·57 to 6·64).

Conclusion

Resection rates have fallen over time for several gastrointestinal cancers. This might reflect increased availability of other treatments, better selection of patients as a result of improved diagnostic accuracy, risk-avoiding behaviour and transparency related to surgical outcomes at hospital and surgeon level.

Preoperative and early postoperative quality of life after major surgery - a prospective observational study

BACKGROUND

Changes in health-related quality of life (HRQoL) several days after surgery have rarely been investigated. We aimed to estimate the perioperative change of HRQoL, to identify patients with clinically relevant decrease in postoperative HRQoL and to establish factors associated with this decrease in HRQoL at day 30 after major surgery.

METHODS

Patients scheduled for major surgery at a university hospital were enrolled. Based on the HRQoL SF-12 questionnaire, the preoperative physical component summary (PCS) score, preoperative mental component summary (MCS) score, and postoperative PCS and MCS scores at day 30 were recorded. Minimal clinically important difference (MCID) was defined as those with a decrease of at least one half of the standard deviation (SD) of preoperative PCS or MCS scores. Differences between the groups with or without decreased HRQoL were investigated using univariate comparisons. A multiple logistic regression model was performed to evaluate the predictive value of potential perioperative variables.

RESULTS

The mean ± SD preoperative PCS score was 38.5 ± 10.6, postoperative score was 35.1 ± 7.8 (p = .004) in 85 patients. Thirty-five patients (41.2%) had a clinically relevant decrease of the postoperative PCS score. A normal to high preoperative exercise metabolic capacity measured with metabolic equivalent of task (MET) (p = .01) was a predictor of the decrease in postoperative PCS. The mean preoperative MCS scores (p = .395) were 42.2 (SD 12.8) preoperative, and 43.45 (SD 12.4) postoperative, respectively.

CONCLUSIONS

Major surgery decreases postoperative PCS scores of HRQoL at 30 days. A normal to high exercise capacity was a predictor of a clinically relevant decrease of postoperative PCS scores.

TRIAL REGISTRATION

07-107 (Ethical Committee NAC of Geneva University Hospitals).

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.

Prediction of long-term mortality by preoperative health-related quality-of-life in elderly onco-surgical patients

Objective

Aim of this study was to evaluate the association between preoperative health-related quality of life (HRQoL) and mortality in a cohort of elderly patients (>65 years) with gastrointestinal, gynecological and genitourinary carcinomas.

Design

Prospective cohort pilot study.

Setting

Tertiary university hospital in Germany.

Patients

Between June 2008 and July 2010 and after ethical committee approval and written informed consent, 126 patients scheduled for onco-surgery were included. Prior to surgery as well as 3 and 12 months postoperatively all participants completed the EORTC-QLQ-C30 questionnaire (measuring self-reported health-related quality of life). Additionally, demographic and clinical data including the Mini Mental State Examination (MMSE) were collected. Surgery and anesthesia were conducted according to the standard operating procedures. Primary endpoint was the cumulative mortality rate over 12 months after one year. Changes in Quality of life were considered as secondary outcome.

Results

Mortality after one year was 28%. In univariable and multivariable logistic regression analysis baseline HRQoL self-reported cognitive function (OR per point: 0.98; CI 95% 0.96–0.99; p = 0.024) and higher symptom burden for appetite loss (per point: OR 1.02; CI 95% 1.00–1.03; p = 0.014) were predictive for long-term mortality. Additionally the MMSE as an objective measure of cognitive impairment (per point: OR 0.69; CI 95% 0.51–0.96; p = 0.026) as well as severity of surgery (OR 0.31; CI 95% 0.11–0.93; p = 0.036) were predictive for long-term mortality. Global health status 12 months after surgery was comparable to the baseline levels in survivors despite moderate impairments in other domains.

Conclusion

This study showed that objective and self-reported cognitive functioning together with appetite loss were prognostic for mortality in elderly cancer patients. In addition, impaired cognitive dysfunction and severity of surgery were predictive for one-year mortality whereas in this selected population scheduled for surgery age, gender, cancer site and metastases were not.

Experts reviews of the multidisciplinary consensus conference colon and rectal cancer 2012: science, opinions and experiences from the experts of surgery

The first multidisciplinary consensus conference on colon and rectal cancer was held in December 2012, achieving a majority of consensus for diagnostic and treatment decisions using the Delphi Method. This article will give a critical appraisal of the topics discussed during the meeting and in the consensus document by well-known leaders in surgery that were involved in this multidisciplinary consensus process. Scientific evidence, experience and opinions are collected to support multidisciplinary teams (MDT) with arguments for medical decision-making in diagnosis, staging and treatment strategies for patients with colon or rectal cancer. Surgery is the cornerstone of curative treatment for colon and rectal cancer. Standardizing treatment is an effective instrument to improve outcome of multidisciplinary cancer care for patients with colon and rectal cancer. In this article, a review of the following focuses; Perioperative care, age and colorectal surgery, obstructive colorectal cancer, stenting, surgical anatomical considerations, total mesorectal excision (TME) surgery and training, surgical considerations for locally advanced rectal cancer (LARC) and local recurrent rectal cancer (LRRC), surgery in stage IV colorectal cancer, definitions of quality of surgery, transanal endoscopic microsurgery (TEM), laparoscopic colon and rectal surgery, preoperative radiotherapy and chemoradiotherapy, and how about functional outcome after surgery?

[Personalized treatment of colorectal cancer in old age]

The incidence of colorectal cancer in elderly patients is rising. Due to changing demographics the topic of personalized treatment of colorectal cancer in old age is of growing importance for interdisciplinary tumor therapy. Besides the oncological results for this group of patients, aspects of risk consideration for treatment, quality of life and the personal conception of life become more relevant. This report covers the changes in comorbidities associated with old age and illustrates the impact on therapeutic strategies and results. Furthermore, it exemplifies potential individual adaption of standardized therapy regimens in multimorbid patients and provides information on possible strategies to improve treatment outcome.

Colorectal cancer survival in the USA and Europe: a CONCORD high-resolution study

OBJECTIVES

To assess the extent to which stage at diagnosis and adherence to treatment guidelines may explain the persistent differences in colorectal cancer survival between the USA and Europe.

DESIGN

A high-resolution study using detailed clinical data on Dukes' stage, diagnostic procedures, treatment and follow-up, collected directly from medical records by trained abstractors under a single protocol, with standardised quality control and central statistical analysis.

SETTING AND PARTICIPANTS

21 population-based registries in seven US states and nine European countries provided data for random samples comprising 12 523 adults (15-99 years) diagnosed with colorectal cancer during 1996-1998.

OUTCOME MEASURES

Logistic regression models were used to compare adherence to 'standard care' in the USA and Europe. Net survival and excess risk of death were estimated with flexible parametric models.

RESULTS

The proportion of Dukes' A and B tumours was similar in the USA and Europe, while that of Dukes' C was more frequent in the USA (38% vs 21%) and of Dukes' D more frequent in Europe (22% vs 10%). Resection with curative intent was more frequent in the USA (85% vs 75%). Elderly patients (75-99 years) were 70-90% less likely to receive radiotherapy and chemotherapy. Age-standardised 5-year net survival was similar in the USA (58%) and Northern and Western Europe (54-56%) and lowest in Eastern Europe (42%). The mean excess hazard up to 5 years after diagnosis was highest in Eastern Europe, especially among elderly patients and those with Dukes' D tumours.

CONCLUSIONS

The wide differences in colorectal cancer survival between Europe and the USA in the late 1990s are probably attributable to earlier stage and more extensive use of surgery and adjuvant treatment in the USA. Elderly patients with colorectal cancer received surgery, chemotherapy or radiotherapy less often than younger patients, despite evidence that they could also have benefited.

Frailty indicators and functional status in older patients after colorectal cancer surgery

OBJECTIVES

The number of older survivors from colorectal cancer is increasing, but little is known regarding long-term consequences of cancer treatment in this patient group. Physical function is an important outcome for older patients, affecting both autonomy and quality of life. We aimed to investigate physical function in older patients with colorectal cancer before and after surgery, and to examine the role of individual frailty indicators as predictors of functional decline.

MATERIAL AND METHODS

We present 16-28 months follow-up data of older patients after elective surgery for colorectal cancer. During a home-visit, physical function was evaluated by activities of daily living (ADL), instrumental activities of daily living (IADL), the timed up-and-go (TUG) test, and grip strength. Measurements were compared with those obtained preoperatively using the Wilcoxon signed rank test. Frailty indicators were dichotomized and implemented in logistic regression models to explore their associations to a decline in the physical function scores.

RESULTS

Eighty-four patients were included and the median age was 82 years. There was a significant decrease in ADL (p = 0.04) and IADL scores (p ≤ 0.001) at follow-up. We found no associations between frailty indicators and the risk of decline in physical functioning.

CONCLUSION

In our population of older patients with surgically treated colorectal cancer, there was a significant decline in ADL- and IADL-scores at follow-up. No change was found in TUG or grip strength, and frailty indicators did not predict decline in physical function.

Poor 1-year survival in elderly patients undergoing nonelective colorectal resection

BACKGROUND

Colorectal resection in elderly patients is associated with significant morbidity and mortality, especially in an emergency setting.

OBJECTIVES

This study aims to quantify the risks associated with nonelective colorectal resection up to 1 year after surgery in elderly patients.

DESIGN

This is a population-based observational study.

SETTING

Data were obtained from the Hospital Episode Statistics database.

POPULATION

All patients aged 70 years and older who underwent a nonelective colorectal resection in an English National Health Service Trust hospital between April 2001 and March 2008 were included.

MAIN OUTCOME MEASURES

: The primary outcomes measured were 30-day in hospital mortality, 365-day mortality, unplanned readmission within 28 days of discharge, and duration of hospital stay.

RESULTS

During the study period, 36,767 nonelective colorectal resections were performed in patients aged ≥ 70 years in England. Patients were classified into 3 age groups: A (70-75 years), B (76-80 years), and C (>80 years). Thirty-day mortality was 17.0%, 23.3%, and 31.0% in groups A, B, and C (p < 0.001). The overall 30-day medical complication rate was 33.7%, and the reoperation rate was 6.3%. Cardiac and respiratory complications were significantly higher in group C (22.2% and 18.2%, p < 0.001). Mortality in Group C was 51.2% at 1-year postsurgery. Advanced age was an independent determinant of mortality in risk-adjusted regression analyses.

LIMITATIONS

This is a retrospective analysis of a prospective database. Stage of disease at presentation, severity of complications, and cause of death cannot be ascertained from this database.

CONCLUSIONS

In this population-based study, half of all English patients aged over 80 years undergoing nonelective colorectal resection died within 1 year of surgery. Further research is required to identify perioperative and postdischarge strategies that may improve survival in this vulnerable cohort.

Long-term survey of patients with curable colorectal cancer with specific reference to the quality of life

Colorectal cancer can be a painful event, generally associated with changes in lifestyle for many patients. We studied the quality of life of the patients operated for colorectal malignancies 5 years after the diagnosis. Using detailed questionnaires, we investigated 220 patients of both sexes (mean age 66.5 years) 5 years (or more) after a curative operation for cancer of the large bowel. The short form 36 (SF-36) questionnaire took into consideration several aspects concerning work activity, physical activity, psychological attitude, alimentation, familial relationships, and other relevant components of lifestyle. Moreover, we compared the perception of the so-called SF-36 score between our patients and a comparison group in the general population. Both univariate and multivariate analysis were used. The obtained results revealed that familial and social relations were equally unchanged or tended to improve. Sexual activity declined in only 61(31.3%) subjects. Rather surprisingly (because of the average age at diagnosis), work activity remained unchanged in about half of the patients. Using the SF-36 questionnaire, the main differences from the general Italian population were seen in bodily pain (especially in the few individuals in whom a permanent stoma was necessary), social functioning and general physical health. In conclusion the results seem to suggest that the majority of patients who survive for more than 5 years after an operation for colorectal malignancy return to an almost normal life. The awareness among individuals about their disease, the improvements in surgical techniques and medical treatments are among the factors responsible for these positive results.

Outcomes of elderly patients undergoing cytoreductive surgery and perioperative intraperitoneal chemotherapy for colorectal cancer peritoneal carcinomatosis

BACKGROUND

The combined treatment of cytoreductive surgery (CRS) and perioperative chemotherapy (PIC) for colorectal peritoneal carcinomatosis (PC) is a rigorous surgical treatment most suited for fit and young patients. With technical maturity and improved perioperative care, we examined the outcomes of elderly patients undergoing CRS and PIC for colorectal PC.

METHODS

All consecutive patients treated in two tertiary centers for PC of colorectal cancer who were 70 years of age or older at the time of surgery were included. Data on patient characteristics, concomitant diseases, operation details, perioperative course, and follow-up were retrieved from medical charts. Primary outcomes were perioperative morbidity and mortality. Secondary outcomes were disease-free and overall survival.

RESULTS

Twenty-four patients (11 male) were included in this study (mean age 73.5 years). In eight patients major complications occurred. In six patients the postoperative course was complicated by minor adverse events. There was no perioperative mortality. Median overall survival was 35 months with a 6, 12, and 18 months survival rate of 94%, 83%, and 68%, respectively.

CONCLUSIONS

CRS and PIC for colorectal PC may be safely performed with acceptable morbidity in selected elderly patients. When considering patients for surgery, performance status, and the disease extent should be used as eligibility criteria rather than age.

Factors affecting recovery of functional status in older adults after cancer surgery

OBJECTIVES

To explore factors influencing functional status over time after cancer surgery in adults aged 65 and older.

DESIGN

Secondary data analysis of combined data subsets.

SETTING

Five prospective, longitudinal oncology nurse-directed clinical studies conducted at three academic centers in the northwest and northeast United States.

PARTICIPANTS

Three hundred sixteen community-residing patients diagnosed with digestive system, thoracic, genitourinary, and gynecological cancers treated primarily with surgery.

MEASUREMENTS

Functional status, defined as performance of current life roles, was measured using the Enforced Social Dependency Scale and the Medical Outcomes Study 36-item Short-Form Survey (using physical component summary measures) after surgery (baseline) and again at 3 and 6 months. Number of symptoms, measured using the Symptom Distress Scale, quantified the effect of each additional common cancer symptom on functional status.

RESULTS

After controlling for cancer site and stage, comorbidities, symptoms, psychological status, treatment, and demographic variables, functional status was found to be significantly better at 3 and 6 months after surgery than at baseline. Factors associated with better functional status included higher income and better mental health. Factors associated with poorer average functional status were a greater number of symptoms and comorbidities. Persons reporting three or more symptoms experienced statistically significant and clinically meaningful poorer functional status than those without symptoms. Persons reporting three or more comorbidities were also found to have poorer functional status than those without comorbidities. No significant relationship existed between age and functional status in patients aged 65 and older.

CONCLUSION

Factors other than age affect recovery of functional status in older adults after cancer surgery.

Colorectal cancer surgery in elderly patients: presentation, treatment, and outcomes

PURPOSE

This study was designed to characterize the presentation, care, and outcomes of persons older than 75 years, compared with persons 50 to 74 years of age, selected for colorectal cancer.

METHODS

Patients over the age of 50 years who had surgery for colon or rectal cancer at the Mount Sinai Hospital between 1997 and 2006 were identified. Data were obtained from a colorectal cancer database and from office and hospital records. Patients were assigned to two groups: 50 to 74 years old and 75 years and older.

RESULTS

There were 623 patients in the younger group (mean age, 62.6 years) and 275 in the older group (mean age, 81.5 years). The in-hospital mortality rate was 1% in the younger group compared with 4.2% in the older (P = 0.002). The overall five-year survival was 68.7% and 57.3% in the younger and older groups, respectively, whereas colorectal cancer-specific five-year survival was not significantly different (74.0% vs. 74.7%). There were significant differences between the two groups with respect to cancer location, American Society of Anesthesiologists' score, stage, proportion detected by screening, length of stay, and use of chemotherapy.

CONCLUSIONS

Long-term colorectal cancer-related outcomes in the older group are similar to the outcomes in younger patients, suggesting that the decision to operate should not be based on age alone.

Older adults and cancer treatment

Approximately 60% of cancer incidence occurs in adults aged > or =65 years, yet older patients often are not accorded access to treatment trials. Therefore, providers remain uninformed about clinical and behavioral responses of older patients with cancer to cancer treatment. The objectives of this article were to provide a broad overview of some of the dimensions of cancer treatment in the elderly and to raise issues for behavioral research. The literature was reviewed in general for cancer treatment and specifically to address areas such as comorbidity, function, adverse events, palliation, side effects, social and psychological factors, cognition, and provider behavior. The authors address the importance of behavioral research and discuss issues for behavioral researchers in the context of cancer treatment. Few studies were identified that were specific to behavioral research. The results indicated that chronological age alone is an inadequate indicator to determine responses among older patients to cancer treatment. When they are selected carefully, older patients can benefit from treatment or palliation. More research is needed to define clinical and behavioral criteria for the inclusion of older patients in treatment trials.

Palliative surgery for rectal cancer in a national cohort

OBJECTIVE

Whether resection of the primary tumour is of benefit to patients with incurable rectal cancer (RC) remains a matter of debate. In this study we analyse prospectively recorded data from a national cohort.

METHOD

Among 4831 patients diagnosed with RC between 1997 and 2001, 838 (17%) patients were treated with palliative surgery. Patients were stratified according to disease stage, age and type of surgery.

RESULTS

A significantly longer median survival, 12 (range 10-13) months, was observed in patients treated with resection of the primary tumour compared with 5 (range 4-6) months in patients treated with nonresective procedures (P < 0.001). Median survival in months was significantly (P < 0.001) related to age (13; < 60 years of age, 10; 60 to 69 years, 7; 70 to 79 years, 6; >/= 80 years of age). In patients over 80 years, survival was similar regardless of the treatment. Thirty-day mortality varied from 2.5% to 20%, according to age groups.

CONCLUSION

The longer survival observed in patients with resection of the primary tumour may partly be explained by patient selection. Elderly patients (>/= 80 years) had a similar survival, irrespective of resection of the primary tumour or not. Careful consideration of the individual patient, extent of disease and treatment-related factors are important in decision-taking for palliative treatment for patients with advanced RC.

Management and survival of colorectal cancer in the elderly in population-based studies

Colorectal cancer is a major problem in elderly patients. Most data on the management and survival of colorectal cancer has been provided by specialised hospital units and as such cannot be used as reference because of unavoidable selection bias. Cancer registries recording data on treatment and survival at a population level represent the best valuable resource to assess the management of patients. However, there is a paucity of reports published in the literature due to the difficulty to routinely collect such data. Relative survival rates in the elderly were lower than in younger patients. However, the gap that has separated younger from elderly patients is closing. Stage at diagnosis remains the major determinant of prognosis. There is also large variation in survival within countries: survival rates being dramatically lower in Eastern European countries, compared to Western European countries. Comorbidity, which is particularly frequent in the elderly, increases the complexity of cancer management and affects survival. Substantial improvement in the care of colorectal cancer in the elderly has been achieved (increase in the proportion of patients resected for cure, decrease in operative mortality, improvement in stage at diagnosis). Surgery should not be restricted on the basis of age alone. Further improvements can be made, in particular with respect to adjuvant therapy.

Multidisciplinary approach to the geriatric oncology patient

Given the dramatic demographic shift observed in developed countries, the medical community, especially oncologists, geriatricians, and primary care providers, are confronted with the expanding challenge of the management of elderly people with cancer. Ageing is associated with the accumulation of multiple and various medical and social problems. With a prevalence comparable to that of other chronic conditions in this age group, such as diabetes or dementia, cancer holds a prominent place among diseases of the elderly. The care of elderly cancer patients is fundamentally interdisciplinary. Communication and collaboration between geriatricians/primary care providers and oncologists represent key features of effective care in geriatric oncology. The combination of the disease-oriented approach of oncologists and the patient-oriented approach of geriatricians is the most powerful way to better serve this specific population. The medical approach of elderly cancer patients should ideally be under the lead of geriatricians or primary care providers sensitive to geriatric issues. Oncologists should manage the biologic consequences of the interplay between cancer and ageing. Close collaboration between clinicians will help promote active dedicated clinical research and the development of guidelines on the management of elderly people with cancer.