Changing treatment patterns in elderly patients with resectable colon cancer

Comorbidity assessment methods and their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer - A scoping review

INTRODUCTION

The scoping review was performed to identify methods of comorbidity assessment and to evaluate their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer.

MATERIALS AND METHODS

Ovid MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov and European Trials Register were searched for eligible studies investigating the impact of comorbidity on various postoperative outcomes of patients aged ≥65. Findings were narratively reported.

RESULTS

The review identified 40 studies with a total population of 59,612 patients, using eight different methods of comorbidity assessment. The most used was Charlson Comorbidity Index (60 % of studies) and presence of specific comorbid conditions (38 %). No study provided rationale for the choice of specific comorbidity measure. Most of the included studies reported short-term results (75 %), such as postoperative complications (43 %) and mortality (18 %) as main clinical endpoint. The results were inconsistent across the studies.

DISCUSSION

There is still no consensus regarding the choice of comorbidity measures and their role in postoperative outcome prediction. Further efforts are needed to develop new, well-designed, more effective comorbidity assessments tools.

Evaluating Surgical Outcomes and Survival in Colon Cancer Patients Over 80 Years Old

BACKGROUND AND AIMS

In the context of an increasing older population, knowing the surgical outcomes of older patients is of paramount importance to define a comprehensive strategy for colon cancer treatment in these patients. This study aimed to analyze the surgical outcomes and survival of patients over 80 years old undergoing surgery for colon cancer.

MATERIALS AND METHODS

This is an observational retrospective longitudinal study of patients over 80 years old with colon cancer diagnosis who underwent surgery for this condition, between 2018 and 2021, in a Portuguese hospital. Demographic and clinical features were characterized. Kaplan-Meier method was used for survival analysis.

RESULTS

Out of 90 patients in the study, 41.1% were female. The majority (56.7%) had an Eastern Cooperative Oncology Group (ECOG) performance status of 1 or 0, with a median Charlson Comorbidity Index of 7.0. Tumors were primarily located in the right colon (52.2%) and sigmoid colon (25.6%), with most patients having stage II (35.6%) or stage III (25.5%) disease. Elective surgeries accounted for 73% of procedures, and 80.0% had curative intent, with laparoscopic surgery performed in 66.7% of cases. Only 8.3% of those undergoing curative-intent procedures received adjuvant chemotherapy. Emergent admissions were associated with more advanced cancer stages, higher rates of palliative intent procedures (45.8% versus 10.6%, p < 0.001), and more open surgeries (75.0% versus 9.1%, p < 0.001) when compared to elective procedures. Postoperative mortality was higher in the emergent group (20.8% versus 10.6%), though there was no association between the type of admission and postoperative complications. Median overall survival for all patients was 36.7 (95% CI 28.1 to 45.3) months, with significant differences between curative-intent and palliative surgeries (median of 39.8 (95% CI 32.6 to 47.0) versus 10.6 (95% CI 0.67 to 20.5) months, p = 0.015). The elective group of patients had significantly better overall survival compared to the emergent group (median of 36.7 (95% CI 30.7 to 42.7) versus 11.9 (95% CI 6.0 to 17.8) months, p = 0.01). Among the patients who underwent curative-intent procedures, there were no significant differences in overall or disease-free survival between elective and emergent groups.

CONCLUSIONS

Despite the increased complexity of managing older patients, particularly in emergent cases, these findings emphasize the importance of elective, curative-intent surgeries to optimize overall survival. Effective treatment strategies and perioperative management tailored to this age group are essential for improving surgical outcomes and extending survival in elderly colon cancer patients.

Oncologic outcomes in elderly patients who underwent hysterectomy for endometrial cancer: a multi-institutional survey in Kinki District, Japan

BACKGROUND

The goal of this study is to assess the oncologic outcomes of elderly patients who underwent hysterectomy for endometrial cancer across three variables: hysterectomy approach, lymph node resection, and adjuvant therapy.

METHODS

Hospital records of patients aged ≥ 70 years who underwent hysterectomy for endometrial cancer were obtained from 19 institutions. Patients were categorized into three risk groups: low, intermediate, and high. In each group, disease-free survival and overall survival were compared according to hysterectomy approach, lymph node resection, and adjuvant therapy using Kaplan-Meier method. Cox regression analysis with a 95% confidence interval was performed to estimate relative risk (RR) of death.

RESULTS

A total of 1246 patients were included. In the low-risk group, the adjusted RR for death for minimally invasive surgery (MIS) versus laparotomy and lymph node resection versus no lymph node resection were 0.64 (0.24-1.72) and 0.52 (0.24-1.12), respectively. In the intermediate-risk group, the adjusted RR for death for MIS versus laparotomy, lymph node resection versus no lymph node resection, and adjuvant therapy versus no adjuvant therapy were 0.80 (0.36-1.77), 0.60 (0.37-0.98), and 0.89 (0.55-1.46), respectively. In the high-risk group, the adjusted RRs for death for lymph node resection versus no lymph node resection and adjuvant therapy versus no adjuvant therapy were 0.56 (0.37-0.86) and 0.60 (0.38-0.96), respectively.

CONCLUSIONS

MIS is not inferior to laparotomy in uterine-confined diseases. Lymph node resection improved the outcome for all disease stages and histological types. In contrast, adjuvant therapy improved the outcomes only in high-risk patients.

Effect of Adjuvant Chemotherapy on Elderly Stage II High-Risk Colorectal Cancer Patients

Purpose

Adjuvant chemotherapy (AC) is recommended for patients with stage II colorectal cancer with adverse features. However, the effect of adjuvant treatment in elderly patients with high-risk stage II colorectal cancer remains controversial. This study aimed to investigate the oncologic outcomes in elderly high-risk stage II colorectal cancer patients who underwent curative resection with or without AC.

Methods

Patients aged over 70 years having stage II colorectal adenocarcinoma with at least 1 adverse feature who underwent radical surgery between 2008 and 2017 at a single center were included. We compared recurrence-free survival (RFS) and overall survival (OS) between patients who received more than 80% of the planned AC cycle (the AC+ group) and those who did not receive it (the AC− group).

Results

The AC+ and AC– group contained 46 patients and 50 patients, respectively. The log-rank test revealed no significant intergroup differences in RFS (P=0.083) and OS (P=0.122). In the subgroup of 27 patients with more than 2 adverse features, the AC+ group (n=16) showed better RFS (P=0.006) and OS (P=0.025) than the AC− group. In this subgroup, AC was the only significant factor affecting RFS in the multivariate analysis (P=0.023). AC was significantly associated with OS (P=0.033) in the univariate analysis, but not in the multivariate analysis (P=0.332).

Conclusion

Among elderly patients with stage II high-risk colorectal cancer, the AC+ group did not show better RFS or OS than the AC− group. However, selected patients with more than 2 adverse features might benefit from AC.

Benefit of Postresection Adjuvant Chemotherapy for Stage III Colon Cancer in Octogenarians: Analysis of the National Cancer Database

BACKGROUND

Clinical trials demonstrate that postresection chemotherapy conveys survival benefit to patients with stage III colon cancer. It is unclear whether this benefit can be extrapolated to the elderly, who are underenrolled in clinical trials.

OBJECTIVE

The purpose of this study was to determine outcomes of selected octogenarians with stage III colon cancer with/without postresection adjuvant therapy.

DESIGN

This was a retrospective cohort study (2006-2011) using unadjusted Kaplan-Meier and adjusted Cox proportional hazards analyses of overall survival.

SETTING

The study was conducted with the National Cancer Database.

PATIENTS

We included patients 80 to 89 years of age who were undergoing curative-intent surgery for stage III colon cancer and excluded patients who received neoadjuvant therapy, died within 6 weeks of surgery, or had high comorbidity.

MAIN OUTCOME MEASURES

Overall survival was the main measure.

RESULTS

A total of 8141 octogenarians were included; 3483 (42.8%) received postresection chemotherapy, and 4658 (57.2%) underwent surgery alone. Patients receiving chemotherapy were younger (82.0 vs 84.0 years; p < 0.001), healthier (73.1% vs 70.4% with no comorbidities; p = 0.009), and more likely to have N2 disease (40.4% vs 32.8%; p < 0.001). Overall survival was improved in patients receiving adjuvant chemotherapy (median = 61.7 vs 35.0 months; p < 0.001). Subgroup analysis of patients offered chemotherapy but refusing (n = 1315) demonstrated overall survival worse than those receiving adjuvant chemotherapy (median = 42.7 vs 61.7 months; p < 0.001). Multivariable analysis adjusting for potential confounders showed therapy with surgery alone to be independently associated with increased mortality hazard (HR = 1.83; p < 0.001), and the mortality hazard remained elevated in patients who voluntarily refused adjuvant therapy (HR = 1.45; p < 0.001).

LIMITATIONS

The study was limited by its retrospective, nonrandomized design.

CONCLUSIONS

In selected octogenarians with stage III colon cancer, postresection adjuvant chemotherapy was associated with superior overall survival. However, less than half of the octogenarians with stage III colon cancer in the National Cancer Database received it. The remaining majority, who were all fit and survived ≥6 weeks postsurgery, could have derived benefit from adjuvant chemotherapy. This represents a substantial opportunity for quality improvement in treating octogenarians with stage III colon cancer.

Clinical features of colorectal cancer patients in advanced age: a population-based approach

In the immediate future, the number of geriatric patients will continue to rise; consequently we should expect an increase of colorectal cancer, a disease of the elderly population. Through the data of a Cancer Registry, we examined (a) the effect of ageing on the main features of colorectal cancer; (b) changes in management, especially for individuals older than 80 years; and (c) changes in prognosis and survival in subgroups of patients with different age. The Registry provided information on colorectal cancer up to 2010 (27 years). A total of 5293 patients were registered; these were divided into three groups: A (0-64 years), B (65-79) and C (80 or more). Three periods of observation were chosen: 1 (1984-1992), 2 (1993-2001) and 3 (2001-2010). Group A included 1571 patients (29 %), Group B 2539 (48 %) and Group C 1183 (22.3 %). The fraction of old individuals increased during the 27 years of the investigation. In these patients, tumours were predominantly localized to the right colon (42.6 %). The rate of surgery and ratio between curative and palliative approaches were similar among the three groups (p < 0.38). There was disparity (p < 0.002) in the administration of chemotherapy (5.8 % of the elderly vs 34.4 % in remaining patients). Survival increased over time in all three groups. In the elderly, average 5-year survival was 31 % in period 1 and 55 % in period 3. These data show that in Western countries, the standard of care for colorectal cancer diagnosed in geriatric patients has improved over the last 30 years.

Colorectal cancer screening and surveillance in the elderly: updates and controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Colorectal cancer of the elderly

OPINION STATEMENT

Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.