Outcomes of octogenarians with esophageal cancer: an analysis of the National Cancer Database

Outcomes After Major Surgical Procedures in Octogenarians: A Nationwide Cohort Study

Introduction

Aging of the worldwide population has been observed, and postoperative outcomes could be worse in elderly patients. This nationwide study assessed trends in number of surgical resections in octogenarians regarding various major surgical procedures and associated postoperative outcomes.

Methods

All patients who underwent surgery between 2014 and 2018 were included from Dutch nationwide quality registries regarding esophageal, stomach, pancreas, colorectal liver metastases, colorectal cancer, lung cancer and abdominal aortic aneurysms (AAA). For each quality registry, the number of patients who were 80 years or older (octogenarians) was calculated per year. Postoperative outcomes were length of stay (LOS), 30 day major morbidity and 30 day mortality between octogenarians and younger patients.

Results

No increase in absolute number and proportion of octogenarians that underwent surgery was observed. Median LOS was higher in octogenarians who underwent surgery for colorectal cancer, colorectal liver metastases, lung cancer, pancreatic disease and esophageal cancer. 30 day major morbidity was higher in octogenarians who underwent surgery for colon cancer, esophageal cancer and elective AAA-repair. 30 day mortality was higher in octogenarians who underwent surgery for colorectal cancer, lung cancer, stomach cancer, pancreatic disease, esophageal cancer and elective AAA-repair. Median LOS decreased between 2014 and 2018 in octogenarians who underwent surgery for stomach cancer and colorectal cancer. 30 day major morbidity decreased between 2014 and 2018 in octogenarians who underwent surgery for colon cancer. No trends were observed in octogenarians regarding 30 day mortality between 2014 and 2018.

Conclusion

No increase over time in absolute number and proportion of octogenarians that underwent major surgery was observed in the Netherlands. Postoperative outcomes were worse in octogenarians.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06642-6.

Surgery provides improved overall survival in surgically fit octogenarians with esophageal cancer after chemoradiation therapy

Background

Multiple randomized controlled trials have shown that multimodal therapy provides the best overall survival for patients who had locally advanced esophageal cancer. However, it is unknown if multimodal therapy offers the best overall survival in octogenarians.

Methods

We performed retrospective cohort study using data obtained from the National Cancer Database (NCDB) for octogenarians who had locally advanced esophageal cancer from 2004 to 2015. We evaluated the 5-year overall survival for patients among different therapies. We compared the 5-year overall survival between patients receiving chemoradiation therapy followed by surgery and a propensity-matched group of patients who underwent chemoradiation only.

Results

There were 21,710 octogenarians (15%) with esophageal cancer in the NCDB database. Among octogenarians, there were 6,960 patients (32%) who had clinical stage II–III esophageal cancer. Among 6,922 patients whose treatment data were available, the most common therapy was chemoradiation (n=3,360, 49%). Two of the most common therapies that included surgical resection were surgery only (n=314, 5%) and chemoradiation therapy followed by surgery (n=172, 2%). Among different treatments, the best 5-year overall survival was achieved in patients receiving chemoradiation therapy followed by surgery (P<0.001). In the propensity score-matched cohort between chemoradiation therapy followed by surgery (n=83) to chemoradiation therapy only (n=83), there was an association with improved 5-year overall survival in the patients who had chemoradiation therapy followed by surgery (17.9%) compared to the patients who underwent chemoradiation only (5.7%, P=0.003).

Conclusions

Most octogenarians with locally advanced esophageal cancer underwent definitive chemoradiation therapy. Very few patients underwent chemoradiation followed by surgery; however, the multimodality treatment provided increased overall survival. Surgically fit octogenarians should be considered for chemoradiation therapy followed by surgery.

Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis

Simple Summary

Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient.

Abstract

Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.

Surgical resection of gastric gastrointestinal stromal tumors (GIST) in octogenarians

BACKGROUND

Localized gastrointestinal stromal tumors (GISTs) are rare tumors typically managed with surgery, but outcomes among octogenarians remain less studied.

METHODS

Octogenarian patients with stage I-III gastric GISTs were identified from the National Cancer Database and classified by resection status. Cox regression and Kaplan-Meier survival analyses analyzed 5-year overall survival (OS). Ninety-day mortality was analyzed following 1:1 propensity score matching.

RESULTS

Identified octogenarians (N = 949) who underwent resection (N = 632) had improved adjusted OS (71% vs 59.6%, HR 0.75, p 0.049) as compared to non-resected patients. Following matching, 90-day mortality was 5.7% and 11% in resected and non-resected patients (p 0.052), respectively. After exclusion of patients with 90-day mortality, resected patients maintained an OS advantage (77.3% vs 71.1%, HR 0.64, p 0.028).

CONCLUSIONS

The majority of octogenarians with localized gastric GIST are treated with surgery portending improved survival but an appreciable mortality, suggesting a necessity for careful selection of older patients for surgery.

Limited Lymph Node Resection Does Not Decrease Postoperative Mortality After Esophagectomy in Octogenarians With Thoracic Esophageal Cancer

BACKGROUND

Octogenarians with esophageal cancer typically have a poor physical condition, reduced physiological reserves, and high postoperative mortality (POM). Extensive lymph node dissection increases surgical trauma and postoperative complications. The purpose of this study was to examine the associations between the number of dissected lymph nodes and short-term and long-term postoperative outcomes in octogenarians with thoracic esophageal cancer.

METHODS

We examined the data of patients from the Surveillance, Epidemiology, and End Results database. We divided the patients into two groups in accordance with the number of lymph nodes dissected: patients with <15 examined lymph nodes (eLNs) and patients with ≥15 eLNs. Mortality was quantified at 30, 60, and 90 d after surgery. Univariable and multivariable logistic regression analyses were performed to identify predictors of 90-day mortality. Kaplan-Meier analysis and the log-rank test were used to analyze the overall survival and cause-specific survival of the patients.

RESULTS

A total of 208 octogenarians with thoracic esophageal cancer were included in the analysis. The 30-day POM rates were 10.3% and 6.9%, the 60-day POM rates were 16.9% and 13.9%, and the 90-day POM rates were 21.3% and 19.4% for patients with <15 eLNs and ≥15 eLNs, respectively. However, the differences in POM between the two groups were statistically nonsignificant (all P > 0.05). In accordance with the multivariable logistic regression analysis, age and marital status were significantly associated with 90-day POM. Furthermore, no significant difference was found between the groups in terms of long-term survival. The 5-year overall survival rates were 29% and 26.8% (P = 0.719) and the 5-year cause-specific survival rates were 43.2% and 34.1% (P = 0.446) in patients with <15 eLNs and ≥15 eLNs, respectively.

CONCLUSIONS

We have demonstrated that octogenarians undergoing esophagectomy are associated with an unacceptably high POM, and less extensive lymph node resection does not decrease POM. Octogenarians may not benefit from esophagectomy with lymphadenectomy. Additional studies need to be conducted to further guide clinicians performing highly selective esophagectomy.

Comparison of Outcomes Between McKeown and Sweet Esophagectomy in the Elderly Patients for Esophageal Squamous Cell Carcinoma: A Propensity Score-Matched Analysis

The aim of this study was to compare the perioperative outcomes and long-term survival rates of the McKeown and Sweet procedures in patients with esophageal cancer younger than 70 years or older than 70 years. A total of 1432 consecutive patients with esophageal squamous cell carcinoma (ESCC) who received surgery at Sun Yat-sen University Cancer Center from January 2009 to October 2012 were analyzed. Propensity score matching was used to balance the clinical characteristics of the patients who underwent different surgical approaches, and 275 and 71 paired cases were matched among those younger and older than 70 years, respectively. The prognosis and postoperative outcomes were compared between the McKeown and the Sweet esophagectomy. For patients younger than 70 years, those who underwent the McKeown procedure had better overall survival (OS) than those in the Sweet group (log rank = 4.467; P = .035). However, no significant difference in disease-free survival and OS was observed between two approaches for the elderly patients (log rank = 1.562; P = .211 and log rank = 0.668; P = .414, respectively). Cox regression analysis revealed that McKeown approach was a positive prognostic factor compared to the Sweet approach for patients younger than 70 years in univariable analysis (HR = 0.790; 95% CI, 0.625-0.997; P = .047), whereas the surgical approach was not significantly related to the prognosis in the elderly patients. For patients older than 70 years, the occurrence of anastomotic fistula increased in those who underwent the McKeown procedure (23.9% vs 11.3%, P = .038, for the McKeown and Sweet esophagectomy, respectively). The McKeown approach increases the OS in younger patients with ESCC. However, for patients older than 70 years, the Sweet approach was proven to be an effective therapy, given the better perioperative outcomes and similar long-term survival compared with patients in the McKeown group.

Outcomes and Tolerability of Definitive and Preoperative Chemoradiation in Elderly Patients With Esophageal Cancer: A Retrospective Institutional Review

Purpose

Our purpose was to report outcomes of elderly patients who underwent definitive treatment involving radiation therapy for esophageal cancer at our institution.

Methods and Materials

We performed a retrospective review of patients aged ≥75 years with esophageal cancer treated with definitive radiation therapy (≥45 Gy) at our institution from 1997 to 2019. Acute and late Radiation Therapy Oncology Group grade 3+ toxicities were recorded. Survival was estimated using the Kaplan-Meier method.

Results

Of the 89 patients included, median age was 80 and 78% were male. Median adjusted Charlson Comorbidity Index and Karnofsky Performance Status were 5 (3-12) and 80 (50-100), respectively. The majority of cancers were adenocarcinoma (58%), distal (67%), and stage III (62%). Fifty-eight percent underwent definitive chemoradiotherapy, and one-third underwent preoperative intent chemoradiotherapy. Median prescribed dose was 50 Gy (45-66 Gy), and intensity modulated radiation therapy was used in 76%. Eighty-five percent completed the radiation therapy course. Among these, 20% had radiation therapy breaks. For those receiving concurrent chemotherapy, 37% had a dose reduction and 39.5% had a break/cycle reduction. Acute grade 3+ toxicity was 22%, with 2% grade 5 toxicity. Twenty-one of the 29 patients (72%) treated with preoperative intent underwent surgery. There were no deaths 90 days postoperatively. For patients who underwent surgery, 1- and 2-year overall survival were 95% and 84%. For those who did not undergo surgery, 1- and 2-year overall survival were 70% and 52%.

Conclusions

There is a role for aggressive radiation therapy in well-selected elderly patients with esophageal cancer. However, optimization of supportive care, chemotherapy regimens, radiation therapy dose/fractionation, and surgical indications are needed to reduce toxicity.