The management of rectal cancer in the elderly

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis

BACKGROUND

The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes.

METHODS

Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type.

RESULTS

A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts.

CONCLUSION

Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Effects of Preoperative Radiochemotherapy with Capecitabine for Resectable Locally Advanced Rectal Cancer in Elderly Patients

Aims and background

Rectal cancer is a common disease of elderly people. However, patients over 70 years of age are often not included in clinical trials. There is a lack of data concerning the use of radiochemotherapy with capecitabine in elderly patients. The aim of this study was to retrospectively evaluate the impact of preoperative radiochemotherapy with capecitabine on downstaging and sphincter preservation and to assess treatment compliance and toxicity in elderly patients.

Methods

Twenty-six patients with resectable locally advanced rectal cancer (stage II-III/TNM) aged >70 years received preoperative radiotherapy and concurrent oral capecitabine 825 mg/m2 twice daily during the whole period of radiotherapy. Two patients who refused surgery after chemoradiation therapy were excluded from the analysis.

Results

Eighty-one percent of patients underwent anterior resection and 18.1% underwent abdominoperineal resection. Overall tumor downstaging, considering both T and N categories, was observed in 18/24 patients (75%). Treatment compliance was good and toxicity rates were similar to those of younger people.

Conclusions

Age is not a contraindication to any therapy and elderly patients who can tolerate radiochemotherapy should be treated like younger patients. Preoperative radiochemotherapy with capecitabine for patients aged >70 years has a good impact on tumor downstaging, increases the feasibility of sphincter-preserving surgery, and is also safe and well tolerated.

Is Chemotherapy or Radiation Therapy in Addition to Surgery Beneficial for Locally Advanced Rectal Cancer in the Elderly? A National Cancer Data Base (NCDB) Study

INTRODUCTION

Current National Comprehensive Cancer Network guidelines for Stages II and III rectal cancer recommend neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. It is unclear whether therapies in addition to surgery are truly beneficial in elderly patients. Our aim was to compare the survival of patients over 80 with Stages II and III rectal cancer undergoing curative intent surgery with or without additional therapy.

MATERIALS AND METHODS

The National Cancer Data Base (NCDB 2006-2011) was queried for patients over 80 with Stages II and III rectal cancer. The primary outcome was overall survival. Patients were stratified based upon therapy group. Univariate group comparisons were made. Unadjusted Kaplan-Meier and multivariable Cox proportional hazards modeling survival analyses were performed.

RESULTS

The query yielded 3098 patients over 80 with Stage II (N = 1566) or Stage III (N = 1532) disease. Approximately, half of the patients received surgery only. Kaplan-Meier analysis showed improved survival for patients receiving neoadjuvant and/or adjuvant therapy in addition to surgery, but there was no significant difference between those that received guideline concordant care (GCC), neoadjuvant chemoradiation only, or post-operative chemotherapy only. Cox proportional hazard modeling identified age >90 and margin positivity as independent risk factors for decreased overall survival.

CONCLUSION

Analysis of NCDB data for Stages II and III rectal cancer in patients over 80 shows a survival benefit of adjuvant and/or neoadjuvant therapy over surgery alone. There does not appear to be a difference in survival between patients who received neoadjuvant chemoradiation, post-resection adjuvant chemotherapy, or GCC.

Outcomes with multimodal therapy for elderly patients with rectal cancer

BACKGROUND

Treatment guidelines for stage II and III rectal cancer include neoadjuvant chemoradiotherapy, surgery and postoperative adjuvant chemotherapy. Although data support this recommendation in younger patients, it is unclear whether this benefit can be extrapolated to elderly patients (aged 75 years or older).

METHODS

This was a retrospective review of patients aged at least 75 years with stage II or III rectal cancer who underwent surgery with curative intent from 1996 to 2013 at the Mayo Clinic. Kaplan-Meier analysis and log rank test were used to compare overall survival between therapy groups. Cox proportional hazards model was used to estimate the independent effect of treatment group on survival.

RESULTS

A total of 160 elderly patients (median age 80 years) with stage II (66) and stage III (94) rectal cancer underwent surgical resection. Only 30·0 and 33·8 per cent received neoadjuvant or adjuvant therapy respectively. Among patients with stage II disease, there was no significant difference in 60-month survival between patients who received any additional therapy and those who had surgery alone (55 versus 38 per cent respectively; P = 0·184), whereas additional therapy improved survival in patients with stage III tumours (58 versus 30 per cent respectively; P = 0·007). Multivariable analysis found a survival benefit for additional therapy in elderly patients with stage III disease (hazard ratio 0·58, 95 per cent c.i. 0·34 to 0·98).

CONCLUSION

A multimodal approach in elderly patients with stage III rectal cancer improved oncological outcomes.

Hospital variation in sphincter preservation for elderly rectal cancer patients

BACKGROUND

The primary goal of an operation for rectal cancer is to cure cancer and, where possible, preserve continence. A wide range of sphincter preservation rates have been reported. This study evaluated hospital variation in the use of low anterior resection (LAR), local excision (LE), and abdominoperineal resection (APR) in the treatment of elderly rectal cancer patients.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare linked data, we identified 4959 patients older than 65 y with stage I-III rectal cancer diagnosed from 2000-2005 who underwent operative intervention at one of 370 hospitals. We evaluated the distribution of hospital-specific procedure rates and used generalized mixed models with random hospital effects to examine the influence of patient characteristics and hospital on operation type, using APR as a reference.

RESULTS

The median hospital performed APR on 33% of elderly patients with rectal cancer. Hospital was a stronger predictor of LAR receipt than any patient characteristic, explaining 32% of procedure choice, but not a strong predictor of LE, explaining only 3.8%. Receipt of LE was primarily related to tumor size and tumor stage, which combined explained 31% of procedure variation.

CONCLUSIONS

Receipt of LE is primarily determined by patient characteristics. In contrast, the hospital where surgery is performed significantly influences whether a patient undergoes an LAR or APR. Understanding the factors that cause this institutional variation is crucial to ensuring equitable availability of sphincter preservation.

Safety of robotic general surgery in elderly patients

As the life expectancy of people in Western countries continues to rise, so too does the number of elderly patients. In parallel, robotic surgery continues to gain increasing acceptance, allowing for more complex operations to be performed by minimally invasive approach and extending indications for surgery to this population. The aim of this study is to assess the safety of robotic general surgery in patients 70 years and older. From April 2007 to December 2009, patients 70 years and older, who underwent various robotic procedures at our institution, were stratified into three categories of surgical complexity (low, intermediate, and high). There were 73 patients, including 39 women (53.4%) and 34 men (46.6%). The median age was 75 years (range 70-88 years). There were 7, 24, and 42 patients included, respectively, in the low, intermediate, and high surgical complexity categories. Approximately 50% of patients underwent hepatic and pancreatic resections. There was no statistically significant difference between the three groups in terms of morbidity, mortality, readmission or transfusion. Mean overall operative time was 254 ± 133 min (range 15-560 min). Perioperative mortality and morbidity was 1.4% and 15.1%, respectively. Transfusion rate was 9.6%, and median length of stay was 6 days (range 0-30 days). Robotic surgery can be performed safely in the elderly population with low mortality, acceptable morbidity, and short hospital stay. Age should not be considered as a contraindication to robotic surgery even for advanced procedures.

Patient's age should not play a key role in clinical decisions on surgical treatment of rectal cancer

BACKGROUND AND AIMS

Recent advances in surgical techniques and adjuvant treatments have decreased morbidity and mortality in patients with rectal cancer. The aim of this study was to clarify the effects of aging on the choice, feasibility and safety of various treatment modalities in patients with rectal cancer.

PATIENTS AND METHODS

During 2003-2006, a total of 274 rectal cancers were diagnosed at Turku University Central Hospital. Patient and tumor characteristics, treatment modalities chosen, and complications were recorded, and patients were followed up prospectively for 1-3 years after treatment. Patients were then divided into two groups: under 75 (n=181) and 75 years or older (n=93) at the moment of diagnosis. Patient data in the two age groups were analysed and compared with each other.

RESULTS

Of the total of 274 patients with rectal cancer, 243 (89%) underwent surgery. The percentage of patients operated was higher (p=0.03) in the younger (92%) than in the older group (83%). The main reasons for non-operative or palliative treatment were severe concomitant diseases and metastasized cancer. Preoperative radiation therapy was given more often (p<0.01) to young (72%) than old (27%) patients. With these selections, there was no difference in 30-day postoperative mortality (1% vs 1%, ns) or postoperative complications (22% vs 34%, ns) between two groups.

CONCLUSION

With preoperative selection, patients over 75 with rectal cancer are suitable for major surgery, as morbidity and mortality rates are comparable to those in younger patients.

Recurrences after local excision for early rectal adenocarcinoma

PURPOSE

The role of local excision in treating rectal cancer patients continues to be controversial. The aim of this study was to evaluate the long-term oncological results of local excision for early rectal adenocarcinomas and review the outcomes of salvage therapy on rectal cancer patients.

MATERIALS AND METHODS

Between March 1992 and September 2005, 35 consecutive patients with early-stage primary rectal adenocarcinomas were treated by local excision with curative intent. The mean tumor distance from the anal verge was 5 cm (range, 1-10 cm).

RESULTS

The median follow-up was 66 months (range, 17-161 months). Pathological examination revealed 23 cases of T1 and 12 cases of T2. Recurrence had developed in 10 patients (6 local recurrences, 4 systemic recurrences). Purely extrapelvic recurrence was observed in only two (5.7%) patients. Of the eight recurrent patients with surgical salvage, five survived with no evidence of disease at the time of this analysis. The 5-year local recurrence-free and disease-free survival rates were 79.6% and 67.9%, respectively.

CONCLUSION

Local excision alone of early-staged rectal adenocarcinomas, even in the ideal candidate, is followed by a relatively higher local recurrence rate than previously reported and may not be a valid modality. Either the use of adjuvant therapy with local excision, even in patients with T1 lesions or the use of preoperative therapy followed by local excision has good promise.

Chemoradiotherapy of anal cancer is feasible in elderly patients: treatment results of mitomycin-5-FU combined with radiotherapy at Helsinki University Central Hospital 1992-2003

The number of elderly patients with cancer is steadily increasing in developed countries and their treatment is a growing challenge for oncological departments. Anal cancer is the first tumour in which chemoradiotherapy with the intent of organ preservation has largely replaced surgery and is an interesting model of modern multimodal oncological treatment. At the Department of Oncology of the Helsinki University Central Hospital we have treated all patients irrespective of age following the same guidelines if there have been no specific contraindications on the basis of intercurrent diseases. The results suggest that the chemoradiotherapy protocol used in the treatment of anal cancer is reasonably well tolerated in elderly patients and the tumour control is comparable to those achieved in younger patients. After successful cancer therapy the life expectancy in these patients can be very long.

Colorectal cancer treatment in elderly patients: an update on recent clinical studies

Colorectal cancer (CRC) is one of the most common cancers in the Western world, with > 500,000 new cases diagnosed each year. One of the strongest risk factors for colon cancer is age. Physicians and their older patients commonly face the dilemma of whether to give/receive systemic chemotherapy for CRC. Evidence supports similar survival benefits with adjuvant and palliative chemotherapy in elderly patients compared with younger age groups. Data on treatment- related side effects did not reveal a different toxicity profile for elderly patients. The safety and efficacy of systemic chemotherapy in fit older patients were proven, and this group of patients could be enrolled in clinical trials. Conversely, frail older patients are more likely to suffer adverse outcomes when faced with stressors and might not benefit from chemotherapy. Despite a growing body of data, a great deal of work is still needed to establish optimal strategies to care for patients diagnosed with cancer later in life. There is a paucity of reports published in the literature because of the difficulty in routinely collecting such data. We report an overview of recent studies (clinical trials, pooled analysis, and population studies) to provide more information and to identify new and better treatment options.

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.

Are we undertreating rectal cancer in the elderly? An epidemiologic study

OBJECTIVE

To better understand the reasons for decreased survival rates in elderly patients with rectal cancer by performing an epidemiologic evaluation of age-related differences in treatment and survival.

SUMMARY BACKGROUND DATA

The incidence of rectal cancer increases with older age, and localized disease can be curatively treated with stage-appropriate radical surgery. However, older patients have been noted to experience decreased survival.

METHODS

Patients with localized rectal adenocarcinoma were identified in the Surveillance, Epidemiology, and End Results database (1991-2002). Cancer-specific survival by age, sex, surgery type, tumor grade, lymph node status, and use of radiation therapy was evaluated using univariate and multivariate regression analysis.

RESULTS

We identified 21,390 patients who met the selection criteria. The median age was 68 years. Each half-decade increase in age > or =70 years was associated with a 37% increase in the relative risk (RR) for cancer-related mortality (RR = 1.37; 95% confidence interval [CI], 1.33-1.42); decreased receipt of cancer-directed surgery (odds ratio [OR] = 0.56; 95% CI, 0.36-0.63); more local excision and less radical surgery (OR = 0.76; 95% CI, 0.72-0.81); less radiotherapy (OR = 0.64; 95% CI, 0.61-0.67); and greater likelihood of N0 pathologic stage classification (OR = 1.10; 95% CI, 1.05-1.15) (P < 0.0001 for each factor). The effect of age on cancer-specific mortality persisted in multivariate analysis with each half-decade increase in age > or =70 years resulting in a 31% increase in cancer-specific mortality (RR = 1.31; 95% CI, 1.25-1.36; P < 0.0001).

CONCLUSIONS

In elderly patients, rectal cancer is characterized by decreased cancer-related survival rates that are associated with less aggressive treatment overall and decreased disease stages at presentation. Investigation into the reasons for these treatment differences may help to define interventions to improve cancer outcomes.

Local excision of rectal tumours by transanal endoscopic microsurgery

BACKGROUND

Transanal endoscopic microsurgery (TEM) allows locally complete excision of rectal tumours and provides an alternative to conventional surgery for benign tumours. However, its role in the curative treatment of invasive carcinoma is controversial. The aim of this study was to determine the morbidity and long-term results for rectal tumours excised by TEM.

METHODS

Between February 1993 and January 2005, 200 patients underwent TEM for excision of adenomas (148) or carcinomas (52). The median tumour distance from the anal verge was 8 (range 1-16) cm.

RESULTS

Mortality and morbidity rates were 0.5 and 14.0 per cent respectively. At a median follow-up of 33 (range 2-133) months, local recurrence had developed in 11 patients (7.6 per cent) with an adenoma. Histological examination of carcinomas revealed pathological tumour (pT) stage 1 in 31 patients, pT2 in 17 and pT3 in four. Immediate salvage surgery was performed in seven patients (13 per cent). At a median follow-up of 34 (range 1-102) months, eight patients (15 per cent) with carcinomas had developed local recurrence. The overall and disease-free 5-year survival rates for patients with carcinomas were 76 and 65 per cent respectively.

CONCLUSION

TEM is an appropriate surgical treatment option for benign rectal tumours. For carcinomas, it is oncologically safe provided that resection margins are clear, but strict patient selection is required.

Local therapy for rectal cancer: still controversial?

PURPOSE

Many considerations, such as morbidity, sexual and urinary dysfunction, or risk of definitive stoma have led to the increased popularity of local therapy in the therapeutic strategy for rectal cancer. However, its role in curative intent is still controversial with oncologic long-term results lower than those obtained by radical surgery.

METHODS

MEDLINE, EMBASE, LILACS, Abstract books, and reference lists from reviews were searched with English language publications to review the current status of evidence for local therapy in rectal cancer, looking especially at the oncologic results and patient selection. We have focused on the new strategies combining neoadjuvant and adjuvant treatment to explain their place in the management of rectal cancer.

RESULTS AND CONCLUSIONS

The key to potentially curative local treatment for rectal cancer is patient selection by identifying the best candidates with preoperative tumor staging and clinical and pathologic assessment of favorable features. Low-risk T1 is suitable for local excision alone. Limited data suggest that adjuvant chemoradiotherapy may be helpful in patients with unfavorable T1 and T2 lesions, achieving a local recurrence rate<20 percent. However, the efficacy of salvage surgery after local excision is uncertain.