Perspectives and limits of cancer treatment in an oldest old population

Robotic versus laparoscopic surgery for colorectal cancer in older patients: a systematic review and meta-analysis

OBJECTIVE

Robotic surgery is being increasingly used for colorectal cancer surgery. However, its utility versus laparoscopic surgery in older patients is unclear. We systematically examined evidence to assess the differences in short-term outcomes of robotic versus laparoscopic surgery for colorectal cancer in older patients.

MATERIAL AND METHODS

Comparative studies published on PubMed, Web of Science, Embase, and CENTRAL databases were searched up to August 30th, 2023.

RESULTS

Seven studies totaling 14,043 patients were included. Meta-analysis showed no difference in the operation time between the robotic and laparoscopic groups. Meta-analysis of ClavienDindo complications showed no difference between the robotic and laparoscopic groups for grades I and II or grades III and IV complications. Similarly, conversion to open surgery, reoperation rates and length of hospital stay were not significantly different between the two groups. Readmission rates and mortality rates were significantly lower with robotic surgery.

CONCLUSION

This first meta-analysis comparing outcomes of robotic and laparoscopic surgery in older colorectal cancer patients shows that both approaches result in no difference in operating time, complication rates, conversion to open surgery, reoperation rates, and LOS. Scarce data shows that mortality and readmission rates may be lower with robotic surgery.

Evaluation of the advantages of robotic versus laparoscopic surgery in elderly patients with colorectal cancer

BACKGROUND

The incidence of colorectal cancer increases with aging. Curative-intent surgery based on a minimally invasive concept is expected to bring survival benefits to elderly patients (aged over 80 years) with colorectal cancer who are frequently with fragile health status and advanced tumors. The study explored survival outcomes in this patient population who received robotic or laparoscopic surgery and aimed to identify an optimal surgical option for those patients.

METHODS

We retrieved the clinical materials and follow-up data on elderly patients with colorectal carcinoma who received robotic or laparoscopic surgery in our institution. The pathological and surgical outcomes were compared to examine the efficacy and safety of the two approaches. The DFS (disease-free survival) and OS (overall survival) results at 3 years after surgery were assessed to explore the survival benefits.

RESULTS

A total of 111 patients were screened for the study, including 55 in the robotic group and 56 in the laparoscopic group. The demographic details were generally similar between the two groups. No statistically significant difference in the number of removed lymph nodes was observed between the two approaches, with a median of 15 versus 14 (P = 0.053). The intraoperative blood loss was significantly reduced by robotic technique when compared to the laparoscopic approach, with a mean of 76.9 ml versus 161.6 ml (P = 0.025). There were no significant differences in operation time, conversion, postoperative complications and recovery, and long-term outcomes between the two groups.

CONCLUSION

Robotic surgery was prized for elderly patients with colorectal cancer who developed anemia and/or hematological conditions.

MRI in the Evaluation of Locally Advanced Vulvar Cancer Treated with Chemoradiotherapy and Vulvar Cancer Recurrence: The 2021 Revision of FIGO Classification and the Need for Multidisciplinary Management

Simple Summary

Vulvar cancer is a rare gynecologic tumor (representing 4% of all gynecologic malignancies). We review the role of MRI in patients with locally advanced vulvar cancer (LAVC), highlighting the findings that influence clinical management. We also present the MRI findings of local recurrence according to its type and location.

Abstract

Magnetic resonance imaging (MRI) plays an essential role in the management of patients with locally advanced vulvar cancer (LAVC), who frequently benefit from a multidisciplinary approach. Accordingly, chemoradiotherapy (CRT) with radical or neoadjuvant intent seems to provide a better quality of life and less morbidity than extensive surgery alone. In this overview, we discuss the role of MRI in the post-CRT assessment of LAVC, emphasizing the evaluation of primary tumor response. In order to assess treatment response and select candidates for post-CRT local excision, the MRI findings are described according to signal intensity, restricted diffusion, enhancement, and invasion of adjacent organs. We also focus on the role of MRI in detecting vulvar cancer recurrence. It occurs in 30–50% of patients within two years after initial treatment, the majority appearing near the original resection margins or in ipsilateral inguinal or pelvic lymph nodes. Finally, we describe early and delayed complications of CRT, such as cellulitis, urethritis, vulvar edema, bone changes, myositis, and fistulization. By describing the role of MRI in assessing LAVC response to CRT and detecting recurrence, we hope to provide suitable indications for a personalized approach.

Characteristics of patients with cancer in European long-term care facilities

Purpose

Up to 26% of residents in nursing homes (NHs) are affected by cancer. Their care represents a challenge, because NHs are not usually considered a setting focused on oncologic management and care. The aim of this paper is to describe socio-demographic and clinical features of patients with cancer residing in European NHs.

Methods

Cross-sectional study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study. Participants were assessed through the interRAI-LTCF, which includes cancer assessment.

Results

Among 4140 participants (mean age 83.4 years; female 73%), 442 (10.7%) had cancer. Patients with cancer had a higher prevalence of do-not-resuscitate directives compared to those without cancer (21.1% vs 16.5%, p = 0.019). Variables directly associated with cancer were male sex (adj OR 1.67, 95% CI 1.36–2.05), pain (adj OR 1.43, 95% CI 1.16–1.77), fatigue (adj OR 1.25, 95% CI 1.01–1.55), polypharmacy (adj OR 1.59, 95% CI 1.21–2.08) and falls (adj OR. 1.30, 95% CI 1.01–1.67). Dementia was inversely associated with cancer (adj OR 0.74, 95% CI 0.58–0.94). Symptomatic drugs such as opioids (23.5% vs 12.2, p < .001), NSAIDS (7.2% vs 3.9%, p = 0.001), antidepressants (39.1% vs 33.8%, p = 0.026) and benzodiazepines (40.3% vs 34.3, p = 0.012) were all prescribed more in participants with cancer compared to those without cancer.

Conclusions

Cancer patients are prevalent in European NHs and they show peculiar characteristics. Studies are needed to evaluate the impact of a supportive care approach on the management of NHs residents with cancer throughout all its phases, until the end-of-life care

Associations Between Anticholinergic Medication Exposure and Adverse Health Outcomes in Older People with Frailty: A Systematic Review and Meta-analysis

Introduction

There are robust associations between use of anticholinergic medicines and adverse effects in older people. However, the nature of these associations for older people living with frailty is yet to be established.

Objectives

The aims were to identify and investigate associations between anticholinergics and adverse outcomes in older people living with frailty and to investigate whether exposure is associated with greater risks according to frailty status.

Methods

MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Web of Science and PsycINFO were searched to 1 August 2019. Observational studies reporting associations between anticholinergics and outcomes in older adults (average age ≥ 65 years) that reported frailty using validated measures were included. Primary outcomes were physical impairment, cognitive dysfunction, and change in frailty status. Risk of bias was evaluated using the Cochrane Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was undertaken where appropriate.

Results

Thirteen studies (21,516 participants) were included (ten community, one residential aged-care facility and two hospital studies). Observed associations included reduced ability for chair standing, slower gait speeds, poorer physical performance, increased risk of falls and mortality. Conflicting results were reported for grip strength, timed up and go test, cognition and activities of daily living. No associations were observed for transitions between frailty states, psychological wellbeing or benzodiazepine-related adverse reactions. There was no clear evidence of differences in risks according to frailty status.

Conclusions

Anticholinergics are associated with adverse outcomes in older people living with frailty; however, the literature has significant methodological limitations. There is insufficient evidence to suggest greater risks based on frailty, and there is an urgent need to evaluate this further in well-designed studies stratifying by frailty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00256-5.

Octogenarians' Breast Cancer Is Associated with an Unfavorable Tumor Immune Microenvironment and Worse Disease-Free Survival

Simple Summary

In recent years, as the elderly population has grown, the number of elderly breast cancer patients has increased, but their biological characteristics are still controversial. This study investigated octogenarians’ breast cancer biology and its tumor microenvironment utilizing an in-silico translational approach to multiple large patient cohorts. We found that octogenarians’ breast cancer was associated with worse survival and an unfavorable tumor immune microenvironment such as M2 macrophage but not with aggressive cancer cell biology. Our report is important for understanding the characteristics of elderly breast cancer patients and would be critical for the development of breast cancer treatment in the future.

Abstract

Elderly patients are known to have a worse prognosis for breast cancer. This is commonly blamed on their medical comorbidities and access to care. However, in addition to these social issues, we hypothesized that the extreme elderly (octogenarians—patients over 80 years old) have biologically worse cancer with unfavorable tumor immune microenvironment. The Cancer Genomic Atlas (TCGA) and the Molecular Taxonomy of Breast Cancer International Consortium (METABRIC) breast cancer cohorts were analyzed. The control (aged 40–65) and octogenarians numbered 668 and 53 in TCGA and 979 and 118 in METABRIC, respectively. Octogenarians had significantly worse breast cancer-specific survival in both cohorts (p < 0.01). Octogenarians had a higher ER-positive subtype rate than controls in both cohorts. Regarding PAM50 classification, luminal-A and -B subtypes were significantly higher in octogenarians, whereas basal and claudin-low subtypes were significantly lower (p < 0.05) in octogenarians. There was no difference in tumor mutation load, intratumor heterogeneity, or cytolytic activity by age. However, the octogenarian cohort was significantly associated with high infiltration of pro-cancer immune cells, M2 macrophage, and regulatory T cells in both cohorts (p < 0.05). Our results demonstrate that octogenarians’ breast cancer is associated with worse survival and with an unfavorable tumor immune microenvironment.