The outcome of surgery for colorectal cancer in the elderly: a 12-year review from the Trafford Database

The influence of age on the outcome of treatment of elderly patients with colorectal cancer

OBJECTIVES

We investigated factors associated with post-operative mortality rates in those aged ≥60, and in particular, the relative survival of age bands within this group.

METHODS

Secondary analysis of a large comprehensive cohort of the elderly treated for colorectal cancer in the North of England during 1998-2003. We investigated seven risk factors associated with 30-day and 6-month post-operative mortality from colorectal surgery.

RESULTS

6083 patients aged ≥60 underwent colorectal cancer surgery. Approximately 8% had died within 30 days of surgery and 17% had died within 6 months. Thirty-day mortality was greater in the elderly (80 years+) compared to the young-old (60-69 years) (adjusted OR: 3.2, 95% CI 2.4 to 4.4). There was neither a significant difference between the proportions offered curative resections across the age-groups, nor was there a significant association between intent of surgery and 30-day mortality. Six-month mortality rose with age, but the association was stronger in those having curative surgery (adjusted OR: 3.8, 95% CI 2.8 to 5.2) than palliative surgery (adjusted OR: 1.5, 95% CI 1.1 to 2.1). Mortality from emergency surgery at 6-months was particularly high in elderly females.

CONCLUSIONS

This large population study adds more weight to the findings that age itself is a major risk factor in the outcome of colorectal surgery in elderly and that 30-day mortality underestimates the longer-term outcome in this age group. There was no significant association between radical resections and 30-day mortality in elderly patients compared to the younger age groups; however, a disproportionately higher mortality at 6 months was seen in elderly female patients.

Anesthesia and perioperative management of colorectal surgical patients - A clinical review (Part 1)

Colorectal surgery is commonly performed for colorectal cancer and other pathology such as diverticular and inflammatory bowel disease. Despite significant advances, such as laparoscopic techniques and multidisciplinary recovery programs, morbidity and mortality remain high and vary among surgical centers. The use of scoring systems and assessment of functional capacity may help in identifying high-risk patients and predicting complications. An understanding of perioperative factors affecting colon blood flow and oxygenation, suppression of stress response, optimal fluid therapy, and multimodal pain management are essential. These fundamental principles are more important than any specific choice of anesthetic agents. Anesthesiologists can significantly contribute to enhance recovery and improve the quality of perioperative care.

[Colorectal surgery in patients over 65 years of age]

BACKGROUND

There is a limited functional reserve in patients over 65 years of age which is conducive to more frequent postoperative complications. Disease extension at the time of diagnosis (clinical stage) and complete tumor resection are two independent risk factors that have a direct influence on survival.

AIMS

To describe the factors that influence morbidity and mortality in patients over 65 years of age after colorectal surgery.

MATERIAL AND METHODS

A retrospective, observational, descriptive study was carried out within the time frame of January 2004 and December 2009 on 105 colon cancer patients after colorectal surgery. They were divided into two groups, one under 65 years of age and the other over 65 years of age, in order to compare preoperative comorbidity, as well as morbidity and mortality 30 days after surgery.

RESULTS

Of the 105 patient total (53,3%), 56 were ≤ 65 years of age. There were complications in 42,8% of the patients, and those of early and less severe presentation were the most frequent; late complications were more frequent in patients ≤ 65 vs > 65 years of age (16,0% vs 10,2%). Overweight (BMI > 25 kg/m(2)) was observed in 35,0% of the study population. Patients > 65 years of age had fewer comorbidities. The most common causes of reintervention were anastomosis dehiscence and postoperative hemorrhage. Mortality in the group was 6,6% and sepsis was the most frequent cause of death.

CONCLUSIONS

Colorectal surgery in patients over 65 years of age has an acceptable complication frequency and a low mortality rate. Our results suggest that patients older than 65 years of age be treated with the same prospects for cure as younger patients.

Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults

Colorectal cancer (CRC) is common among older adults and surgical resection with curative intent is the primary treatment of CRC. Despite the changing demographics of CRC patients and increasing prevalence of multiple comorbidities, surgery is increasingly performed in this complex aging population. Clinically important short-term outcomes have improved for this population, but little is known about long-term outcomes. We review the literature to evaluate trends in CRC surgery in the geriatric population and the outcomes of surgical treatment. We explore the specific gaps in understanding longitudinal patient-centered outcomes of CRC treatment. We then propose adaptations from the geriatrics literature to better predict both short and long-term outcomes after CRC surgery. Interventions, such as prehabilitation, coupled with comprehensive geriatric assessment may be important future strategies for identifying vulnerable older patients, ameliorating the modifiable causes of vulnerability, and improving patient-centered longitudinal outcomes. Further research is needed to determine relevant aspects of geriatric assessments, identify effective intervention strategies, and demonstrate their validity in improving outcomes for at-risk older adults.

Impact of age-related comorbidity on results of colorectal cancer surgery

AIM: To analyze the correlation between preexisting comorbidity and other clinicopathological features, short-term surgical outcome and long-term survival in elderly patients with colorectal cancer (CRC).

METHODS: According to age, 403 patients operated on for CRC in our department were divided into group A (< 70 years old) and group B (≥ 70 years old) and analyzed statistically.

RESULTS: Rectal localization prevailed in group A (31.6% vs 19.7%, P = 0.027), whereas the percentage of R0 resections was 77% in the two groups. Comorbidity rate was 46.2% and 69.1% for group A and B, respectively (P < 0.001), with a huge difference as regards cardiovascular diseases. Overall, postoperative morbidity was 16.9% and 20.8% in group A and B, respectively (P = 0.367), whereas mortality was limited to group B (4.5%, P = 0.001). In both groups, patients who suffered from postoperative complications had a higher overall comorbidity rate, with preexisting cardiovascular diseases prevailing in group B (P = 0.003). Overall 5-year survival rate was significantly better for group A (75.2% vs 55%, P = 0.006), whereas no significant difference was observed considering disease-specific survival (76.3% vs 76.9%, P = 0.674).

CONCLUSION: In spite of an increase in postoperative mortality and a lower overall long-term survival for patients aged ≥ 70 years old, it should be considered that, even in the elderly group, a significant number of patients is alive 5 years after CRC resection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Benefits of laparoscopic colorectal resection are more pronounced in elderly patients

PURPOSE

The purpose of this study was to evaluate the impact of laparoscopic colorectal resection on short-term postoperative outcome in elderly patients.

METHODS

A series of 535 patients with colorectal disease who had been randomly assigned to laparoscopic (n=268) or open (n=267) resection was analyzed. A total of 201 patients (37.6 percent) were elderly (aged 70 years or older) and 334 patients (62.4 percent) were younger than aged 70 years. Follow-up for postoperative morbidity was performed for 30 days after hospital discharge.

RESULTS

Elderly patients had a higher American Society of Anesthesiologists score compared with younger patients in both the laparoscopic and open groups (P=0.0001). In the open group, elderly patients had higher morbidity rate (37.5 vs. 23.9 percent; P=0.02) and longer length of hospital stay (13 vs. 10.6; P=0.007) compared with younger patients. In the laparoscopic group, morbidity rate (20.2 vs. 15.1 percent) and length of hospital stay (9.5 vs. 9.1) were similar in elderly and younger patients. In elderly patients, the laparoscopy-reduced morbidity rate (20.2 vs. 37.5 percent; P=0.01) and length of hospital stay (9.5 vs. 13; P=0.001) compared to the open approach. In younger patients, the advantages of the laparoscopic approach on morbidity rate (15.1 vs. 23.9 percent; P=0.06) and length of stay (9.1 vs. 10.6; P=0.004) were less pronounced.

CONCLUSIONS

Laparoscopy improved short-term postoperative outcome more in elderly than in younger patients. Advanced age was associated with higher morbidity and longer length of stay only in patients who underwent open colorectal surgery.

Long-term outcome after operative intervention for rectal cancer in patients aged over 80 years: analysis of 9,501 patients

INTRODUCTION

Perceptions of poor outcome may detract caregivers from offering standard therapies to patients over 80 years who have been diagnosed with rectal cancer. We evaluate the effect of operative intervention on their survival.

METHODS

Demographics, tumor characteristics, treatment, and survival for patients over 80 years with rectal and rectosigmoid cancer from 1993 to 2002 in the Surveillance, Epidemiology and End Results Program of the National Cancer Institute were examined. Survival was determined by using the Kaplan-Meier method. Patients who underwent operation (Group A) were compared with those who did not undergo surgery (Group B). Fisher's exact, chi-squared, analysis of variance, and log-rank tests were used as appropriate, and P < 0.05 was considered statistically significant.

RESULTS

A total of 9,501 patients (19 percent) were aged older than 80 years. Mean age was 85 years, and median survival was 24 months. Stage of disease was unknown for 2,915 patients. Median survival was 58, 53, 39, 27, and 5 months for Stages 0 (n=163), I (n=1,878), II (n=1,796), III (n=1,536), and IV (n=1,213), respectively. A total of 6,900 patients (81 percent) underwent surgery. Median survival for operated patients was significantly longer for all stages (36 vs. 5 months, P < 0.00001), Stage 0 (60 vs. 7 months, P < 0.01), Stage I (55 vs. 11 months, P < 0.0001), Stage II (41 vs. 13 months, P < 0.0001), Stage III (28 vs. 14 months, P < 0.05), and Stage IV (8 vs. 3 months, P < 0.0001). For patients with rectal cancer, local therapy also significantly improved median survival compared with nonoperated patients (P < 0.0001).

CONCLUSIONS

Operative intervention provides sustained benefit in terms of survival to patients aged >80 years with rectal cancer at all stages who are assessed to be a good operative risk. Age older than 80 years should not detract surgeons from offering optimal therapy to good-risk patients.

Population-based assessment of the surgical management of locally advanced colorectal cancer

BACKGROUND

Evidence-based guidelines recommend multivisceral resection for patients with locally advanced adherent colorectal cancer because it reduces local recurrence and improves survival. However, this procedure can increase morbidity compared with standard resection and may not be practiced uniformly. We performed a population-based study to examine surgical practice and outcomes among patients with locally advanced adherent colorectal cancer in the United States.

METHODS

Patients who were 18 years or older and who had surgical resection for nonmetastatic, locally advanced adherent colorectal cancer from January 1, 1988, through December 31, 2002, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Logistic regression was used to examine patient, tumor, and geographic factors associated with multivisceral resection. Cumulative early mortality (i.e., at 1 and 6 months after diagnosis) and 5-year survival were obtained from Kaplan-Meier estimates; adjusted risks of death were calculated using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

We identified 8380 patients who underwent surgical resection for locally advanced adherent colorectal cancer, of whom 33.3% were managed with multivisceral resection. Among colon cancer patients, younger age at diagnosis, female sex, SEER region, node negativity, and left-sided tumors were independently associated with having had a multivisceral resection. Among rectal cancer patients, younger age at diagnosis and female sex were positively and statistically significantly associated with multivisceral resection, whereas receipt of neoadjuvant radiation was inversely and statistically significantly associated with multivisceral resection. Compared with standard resection, multivisceral resection was associated with improved overall survival for patients with colon (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.83 to 0.96) and rectal (HR = 0.81, 95% CI = 0.70 to 0.94) cancer, with no associated increase in early mortality.

CONCLUSIONS

The majority of patients with locally advanced colorectal cancer did not receive a multivisceral resection. The geographic variation in the application of this procedure in patients with colon cancer suggests that local organizational structures and processes of care may play an important role in patient treatment and, therefore, prognosis.

Treating renal cell cancer in the elderly

OBJECTIVE

To determine whether age and comorbidity are predictors of peri-operative complications and/or mortality in surgery for renal cell cancer in a retrospective study of patients aged >75 years.

PATIENTS AND METHODS

Between 1993 and 2003, 1023 radical nephrectomies or nephron-sparing surgery for renal cell cancer were performed in 115 consecutive patients aged > or = 75 years and in 908 consecutive patients aged <75 years. The preoperative American Society of Anesthesiologists (ASA) score was used for risk stratification. Operative mortality and early complications (within 30 days of surgery) were reviewed.

RESULTS

The younger patients had significantly lower ASA scores than the older patients. There were early complications in 31 of the 908 younger patients (3.4%) and in two of the 115 older patients (1.7%). Peri-operative mortality was higher in the older than in the younger patients (1.7% vs 0.3%; P = 0.29). Overall morbidity and mortality correlated with increasing ASA score but not with age (P < 0.05).

CONCLUSIONS

Despite greater comorbidity in older patients, their morbidity and mortality did not differ significantly from that of younger patients. Advanced age alone should thus not be used as a criterion to deny surgery for renal cell carcinoma. However, older patients should be counselled regarding a tendency for increased comorbidity-related peri-operative mortality.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Pre-emptive antibiotic treatment vs 'standard' treatment in patients with elevated serum procalcitonin levels after elective colorectal surgery: a prospective randomised pilot study

BACKGROUND

Procalcitonin (PCT) is regarded as a specific indicator of bacterial infection. Infectious complications in patients after colorectal surgery are a common cause of morbidity and mortality. The aim of this study was to investigate (a) whether PCT could serve as a negative predictive marker for postoperative complications and (b) whether, in patients with elevated PCT levels, a pre-emptive treatment with the third-generation cephalosporin ceftriaxone is superior to an antibiotic treatment starting later on the appearance of clinical signs and symptoms of infection.

PATIENTS AND METHODS

By screening 250 patients with colorectal surgery, we identified 20 patients with PCT serum levels more than 1.5 ng/ml on at least 2 of the first 3 postoperative days. The remaining 230 patients were followed-up for the occurrence of infectious complications. The 20 patients with elevated PCT were included in a prospective randomised pilot study comparing pre-emptive antibiotic treatment with ceftriaxone vs standard treatment.

RESULTS

The negative predictive value of PCT for systemic infectious complications was 98.3%. In patients receiving pre-emptive antibiotic treatment (ceftriaxone), both the incidence and the severity of postoperative systemic infections were significantly lower compared to those in a control group (Pearson's chi(2) test; p=0.001 and p=0.007, respectively). Major differences were also observed with respect to duration of antibiotic treatment and length of hospital stay.

CONCLUSIONS

PCT is an early marker for systemic infectious complications after colorectal surgery with a high negative predictive value. A significant reduction in the rate of postoperative infections in patients with elevated PCT serum concentrations was achieved by means of pre-emptive antibiotic treatment.

Presentation, treatment, and multivariate analysis of risk factors for obstructive and perforative colorectal carcinoma

BACKGROUND

It is known that emergency surgery for colorectal cancer is associated with high morbidity and mortality. The aim of this study was to assess the presentation, treatment, and outcome of patients with complicated colorectal cancer. Risk factors for morbidity and mortality were also evaluated.

METHODS

From 1991 to 2002, the medical records of 107 consecutive patients undergoing emergency surgery for obstructing or perforating colorectal carcinoma were retrospectively reviewed. Information regarding patient and tumor characteristics, treatment, and outcome was recorded. Risk factors were assessed by multivariate analysis.

RESULTS

Eighty-three patients (78%) had complete obstruction and 24 (22%) had perforation. Overall and major complications occurred in 70% and 34%, respectively. The mortality rate was 15%. Independent risk factors for major morbidity were perioperative blood transfusion and high American Society of Anesthesiologists (ASA) class, whereas those for mortality were older age and high Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

CONCLUSIONS

Emergency surgery for complicated colorectal carcinoma carries high rates of morbidity and mortality. To achieve improvements in outcome, intensive treatment after surgery in patients with risk factors is recommended.

Thirty-day mortality after surgery for colorectal cancer in Denmark

OBJECTIVE

This study aimed to estimate the 30-day mortality after colorectal cancer (CRC) surgery in Denmark. Mortality was compared to other studies, and between departments, unadjusted and adjusted for case-mix.

MATERIALS AND METHODS

All patients in Denmark with a first-time colorectal adenocarcinoma operated between 1 May 2001 and 31 December 2002 were eligible, 5187 patients were included. Mortality was adjusted for age, sex, urgency, tumour location, Dukes' stage and ASA-score.

RESULTS

The 30-day mortality in Denmark after CRC-surgery was 9.9%. Adjusted for case-mix, four departments had significantly higher mortality than average. The variation between the 44 departments was significant both for radically operated (P = 0.02) patients and for all operated patients (P = 0.01).

CONCLUSION

The 30-day mortality in Denmark seems to be higher than in studies from other countries, but the lack of comparable nationwide studies makes it difficult to evaluate. To uncover the reasons for the departments to diverge significantly from average, further studies are needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Elderly Patients in Surgical Workloads: A Population-Based Analysis

Elderly (80+ year old) individuals are the fastest-growing segment of the U.S. population. The objective of this study was to use population-based data to examine trends in the number of elderly undergoing major general, vascular, and cardiothoracic surgical procedures. California inpatient data from 1990–2000 was used to identify patients undergoing six procedures: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), carotid endarterectomy (CEA), colon resections, lung resections, and pancreatic resections. Despite comprising only 2.7 per cent of the California population, elderly patients were a significant percentage (6–22%) of the caseloads for the six procedures examined. For all six procedures, the percentage of patients that were elderly increased during the study period. The age-specific incidence rates for elderly individuals increased significantly for three of these procedures (CABG, CEA, lung resection), remained unchanged for two (AAA, pancreas resection), and decreased for one (colon resection). Elderly patients are a large and growing part of surgical caseloads. In the near future, the number of elderly individuals in the California state and the U.S. populations will increase dramatically (41% and 35% between 2000 and 2020). To provide the best quality of care, surgeons should embrace research, training, and educational opportunities regarding the treatment of elderly patients.

Major colorectal cancer resection should not be denied to the elderly

AIMS

Adjuvant therapy after surgery for colorectal cancer is often denied to the elderly for various reasons. This study was to determine morbidity and mortality risk after surgery in the elderly and whether this is affected by adjuvant therapy.

METHODS

Data were collected prospectively and entered on a database for all patients undergoing resection of colorectal cancer between January 1994 and July 2000. A total of 304 patients were included, 65 aged 80 years and over.

RESULTS

There were 84 deaths, 21 (30%) in the over 80s, and 63 (26%) in the under 80s (P=0.51). The 'in-hospital' mortality was 10.1% in the over 80s and 3.8% in the under 80s (P=0.056). In the over 80s the colon was more affected than the rectum (P=0.002). The over 80s were less likely to be offered adjuvant therapy, 7.2% vs 42.1% (P<0.001). The 5 year survival (all-cause mortality) in the over 80s was 58.5% and 47.6% in the under 80s (P=0.25). Cox's regression analysis of all patients identified the following factors to be independently related to overall survival: age>80 years, post-operative leak, increasing Dukes stage and distant recurrence of disease.

CONCLUSION

This study has demonstrated that surgery should not be denied to elderly patients with colorectal cancer as despite a higher post-operative morbidity and mortality rate and with the absence of adjuvant therapy, favourable long-term outcome can be achieved by resectional surgery alone.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

How should patients 80 years of age or older with colorectal carcinoma be treated? Long-term and short-term outcome and postoperative cytokine levels

PURPOSE

The aim of this study was to determine how extensive resection affects operative morbidity, mortality, and long-term survival in elderly patients with colorectal cancer.

METHODS

A total of 119 patients 80 years of age or older were given a diagnosis of colorectal carcinoma at our hospital between 1985 and 1997. Eleven patients who did not undergo surgery were excluded. The remaining 108 patients underwent laparotomy and were reviewed. Serum levels of interleukin-6 were measured perioperatively in 22 patients to assess the degree of operative stress.

RESULTS

Potentially curative resection was performed in 64 (88.9 percent) of the 72 patients in the active performance status group and 13 (36.1 percent) of the 36 patients in the sedentary performance status group (P < 0.001). The in-hospital mortality rate was 8.3 percent in group the active performance status group and 38 percent in the sedentary performance status group (P = 0.007). Patients in the sedentary performance status group and those who underwent emergency operations had higher levels of IL-6 than patients in the active performance status group or those who underwent elective operations.

CONCLUSIONS

Preoperative performance status, operative curability, and tumor stage have a significant impact on outcome in patients with colorectal cancer who are 80 years of age or older. Knowledge of early postoperative response of IL-6 is useful in predicting postoperative mortality and morbidity in this subgroup of patients.

Cancer surgery in the elderly

The incidence of most cancers increases with age. Although the risk for surgery increases in elderly patients who have comorbidities, evaluations of risk can allow interventions that may decrease morbidity and mortality. Appropriate treatments should be offered to the elderly until studies demonstrate the elderly can safely be managed differently from younger patients. The elderly should not be denied adequate treatment simply because of age.

Treatment of colorectal cancer in patients aged over 75

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

Survival of colorectal carcinoma in the elderly. A prospective study of colorectal carcinoma and a five-year follow-up

PURPOSE

Colorectal carcinoma in elderly patients has become a more common problem in the last decade. There are some physicians who tend to offer a less definitive treatment for these patients because of their chronologic age. The purpose of this study was to evaluate the long-term survival of elderly patients (> 70) who underwent surgery for colorectal carcinoma in comparison with a younger group of patients with the same disease.

METHODS

Long-term survival of patients with colorectal carcinoma who underwent surgery was prospectively evaluated. Long-term survival was compared between an elderly group of patients (age, > 70) and a younger group of patients.

RESULTS

There was no significant difference in the five-year survival between the two age groups. Patients' survival was influenced by stage of the disease and type of operation (emergency vs. elective).

CONCLUSIONS

Treatment decisions in elderly patients with colorectal carcinoma should not be influenced by the chronologic age of the patient.

Elective surgery for gastrointestinal tumours in the elderly

The geriatric population is expanding and clinical decision-making is often complicated by the effects of ageing. Age should not be the only parameter considered when addressing medical problems. Elderly subjects have been denied surgery because of their presumed higher mortality and morbidity. The present review summarises the physiology of the aged and discusses operative risks, mortality and morbidity rates as well as therapeutic results for the different gastrointestinal sites when affected by cancer. Reports on surgical treatments are revisited and compared to the same procedures delivered to younger patients in the context of the ethical issue of offering the best care to every patient. Elective operations by surgical oncologists are found to be safe with the exception of major liver resections. Complication rates and mean hospital stay do not differ between the two age groups provided the procedure is conducted with the best-known technique in expert hands. A drop in operative morbidity has occurred in the past three decades. Several investigators have emphasised the marked increase in morbidity and mortality experienced by elderly patients when undergoing emergency procedures. Associated diseases have to be properly assessed, as the elderly have a frail physiological balance with a reduced capacity for recovery from traumatic events including major surgical procedures. Careful preoperative evaluation, intraoperative conduct and postoperative care are presently achieved in almost every major hospital. Good clinical practice is based on the balance between probability of cure and toxic effects. Treatment of the elderly should no longer be based on untested beliefs and personal opinions. The elderly should be accrued for prospective clinical evaluation and should not be denied optimal surgical treatment.

Elective surgery for colorectal cancer in the aged: a clinical-economical evaluation

A series of 56 consecutive patients, referred for surgery to a specialized institute, had elective laparotomies with various surgical procedures aimed at curing locoregional colorectal cancer. Data defining patient and tumour-related preoperative, operative and postoperative variables, including costs, were collected. The study group was divided into two age groups (< 65 vs > or = 65 years), which were similar in terms of patient- and tumour-related variables. Differences were not statistically significant (Pounds 440; 95% exact CI; Pounds -50; 1800). There is no evidence to suggest that there are any total charge differences in treating the two age groups, as confirmed by the cost analysis.