Clinical characteristics and prognosis of elderly patients with colorectal cancer: Comparison between surgical resection and supportive care

The association of postoperative morbidity and age on 5-year survival after colorectal surgery in the elderly population: a nationwide cohort study

AIM

This study aimed to evaluate the association of age and postoperative morbidity on 5-year overall survival (OS) after elective surgery for colorectal cancer.

METHOD

Patients undergoing elective, curatively intended surgery for colorectal cancer Union for International Cancer Control Stages I-III between January 2014 and December 2019 were selected from four Danish nationwide healthcare databases. Patients were divided into four groups: group I 65-69 years old; group II 70-74 years old; group III 75-79 years old; and group IV ≥80 years old. Propensity score matching was used to reduce potential confounding bias. The primary outcome was the association of age and postoperative morbidity with 5-year OS. The secondary outcome was conditional survival, given that the patient had already survived the first 90 days after surgery.

RESULTS

After propensity score matching with a 1:1 ratio, group II contained 2221 patients; group III 952 patients; and group IV 320 patients. There was no significant difference in 5-year OS between group I (reference) and groups II and III (P = 0.4 and P = 0.9, respectively). Patients with severe postoperative complications within 30 days after surgery had a significantly decreased OS (P < 0.01); however, when patients who died within the first 90 days were excluded from the analysis, the differences in 5-year OS were less pronounced across all age groups.

CONCLUSION

Postoperative morbidity, and not patient age, was associated with a lower 5-year OS. Long-term survival for patients who experience a complication is similar to patients who did not have a complication when conditioning on 90 days of survival.

Analysis of competing risks of cardiovascular death in patients with hepatocellular carcinoma: A population-based study

Clinical data has shown that cardiovascular diseases (CVDs) have emerged as a prominent cause of mortality in individuals with hepatocellular carcinoma (HCC). This research aimed to reveal the comorbid effects of CVDs in patients with HCC. The cardiovascular mortality of patients diagnosed with HCC between 2000 and 2014 was compared to that of the general US population. Standardized mortality ratios were calculated to quantify the relative risk of cardiovascular mortality in HCC patients. The cumulative incidence of cardiovascular death (CVD) was estimated using Fine-Gray testing, and independent risk factors for CVD were determined using competing risk models. The results were analyzed using the Kaplan-Meier analysis. The overall SMR for CVD in HCC patients was 11.15 (95% CI: 10.99-11.32). The risk of CVD was significantly higher in patients aged < 55 years (SMR: 56.19 [95% CI: 54.97-57.44]) compared to those aged ≥ 75 years (SMR: 1.86 [95% CI: 1.75-1.97]). This study suggests that patients with HCC are at significant risk of developing CVD. Competing risk analyses indicated that age, grade, tumor size, surveillance, epidemiology, and end results stage, and surgical status were independent risk factors for CVD in patients with HCC. Therefore, patients with HCC require enhanced preventive screening and management of CVDs during and after treatment to improve patient survival.

Frailty and Colorectal Surgery: Review and Concept of Cancer Frailty

Frailty is characterized by reduced physiological reserves across multiple systems. In patients with frailty, oncological surgery has been associated with a high rate of postoperative complications and worse overall survival. Further, given that cancer and frailty can co-exist in the same patient, cancer and cancer-related symptoms can rapidly accelerate the progression of baseline frailty, which we have termed "cancer frailty". This distinction is clinically meaningful because the prioritization of interventions and the treatment outcomes may differ based on health conditions. Specifically, in patients with cancer frailty, improvements in frailty may be achieved via surgical removal of tumors, while prehabilitation may be less effective, which may in turn result in delayed treatment and cancer progression. In this review, we focused on challenges in the surgical treatment of non-metastatic colorectal cancers in patients with frailty, including those related to decision making, prehabilitation, and surgery. Potential recommendations for treating patients with cancer frailty are also discussed.

Is Palliative Gastrojejunostomy for Malignant Gastric Outlet Obstruction an Optimal Choice for Very Elderly Patients? A Report from a Long-Lived Country

BACKGROUND

Gastrojejunostomy (GJ) is a surgical option for malignant gastric outlet obstruction (mGOO). Confronting an aging society, the demand to treat elderly cancer patients with unresectable malignancies is increasing; however, the benefit of GJ to the very elderly (≥ 80 years of age) has never been investigated.

METHODS

This multicenter, retrospective review included 108 patients who had undergone GJ for mGOO from two medical centers in Japan, one of the most long-lived countries. Patients were divided into two groups, with 80 years of age as the cut-off. Various factors, including surgical complications and patient survival, were compared.

RESULTS

GJ in the very elderly (aged ≥ 80 years) was associated with a higher incidence of surgical complications (p = 0.049), such as delayed gastric emptying (DGE; p < 0.001), aspiration pneumonia (p = 0.029), and consequent mortality (p = 0.016). Age ≥80 years was also identified as an independent predictor of DGE (odds ratio 6.444, p = 0.005) and survival after GJ (hazard ratio 7.767, p = 0.016). In particular, the median survival time after GJ in the population aged ≥80 years with gastric cancer was only < 2 months. About the surgical procedure, antiperistaltic anastomosis with partial stomach partitioning (PSP) yielded the lowest occurrence rate of DGE (3.4%) and aspiration pneumonia (1.7%).

CONCLUSIONS

GJ does not seem to be the optimal choice for very elderly patients, particularly those with gastric cancer. If performed, antiperistaltic anastomosis with PSP should be employed to reduce the surgical complications.

The efficacy of the American College of Surgeons Surgical Risk Calculator in the prediction of postoperative complications in oncogeriatric patients after curative surgery for abdominal tumors

BACKGROUND

The American College of Surgeons (ACS) has developed a Surgical Risk Calculator (SRC) to predict postoperative surgical complications. No studies have reported the performance of the ACS-SRC in oncogeriatric patients. Our objective was to evaluate the predictive performance of the ACS-SRC in these patients, treated with curative surgery for an abdominal malignancy.

METHODS

This is a retrospective study including 136 patients who underwent elective abdominal oncological surgery, between 2017 and 2019, at our institution. Postoperative complications were classified according to the ACS-SRC, and its predictive performance was analyzed by assessing discrimination and calibration and using receiver operating characteristics and area under the curve (AUC).

RESULTS

Discrimination was adequate with AUC of 0.7113 (95% confidence interval [CI]: 1.062-1.202, p = 0.0001; Brier 0.198) for serious complications and 0.7230 (95% CI: 1.101-1.756, p = 0.0057; Brier 0.099) for pneumonia; and poor for sepsis, surgical site infection (SSI), and urinary tract infection (UTI) with AUCs of 0.6636 (95% CI: 1.016-1.353, p = 0.0299; Brier 0.142), 0.6167 (95% CI: 1.003-1.266, p = 0.0450; Brier 0.175), and 0.6598 (95% CI: 1.069-2.145, p = 0.0195; Brier 0.082), respectively.

CONCLUSION

The ACS-SRC is an adequate predictor for serious complications and pneumonia in oncogeriatric patients treated surgically for abdominal cancer. However, the predictive power of the calculator appears to be low for sepsis, UTI, and SSI.