Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy

Prognostic Factors and Outcomes in Elderly Esophagectomy Patients with Esophageal Cancer

BACKGROUND

Choosing the appropriate treatment for elderly patients with esophageal cancer remains a contentious issue. While surgery is still a valid option, we aimed to identify predictors and outcomes in elderly esophagectomy patients with esophageal cancer.

PATIENTS AND METHODS

We analyzed characteristics, surgical outcomes, survival rates, cause-specific mortality, and recurrence in 120 patients with stage I-IV esophageal cancer. Univariate and multivariate analyses were used to identify risk factors for event-free survival (EFS) and overall survival (OS).

RESULTS

The median follow-up period was 31 months, with 5-year overall survival (OS) and event-free survival (EFS) rates standing at 45.2% and 41.5%, respectively. Notably, lower body mass index (BMI ≤ 22 kg/m2) and reduced preoperative albumin levels (pre-ALB < 40 g/L) led to a significant decrease in OS rates. Postoperative pulmonary complications resulted in higher in-hospital and 90-day mortality rates. After about 31 months post-surgery, the rate of cancer-specific deaths stabilized. The most common sites for distant metastasis were the lungs, supraclavicular lymph nodes, liver, and bone. The study identified lower BMI, lower pre-ALB levels, and postoperative pulmonary complications as independent risk factors for poorer EFS and OS outcomes.

CONCLUSIONS

Esophagectomy remains a safe and feasible treatment for elderly patients, though the prevention of postoperative pulmonary infection is crucial. Factors such as lower BMI, lower pre-ALB levels, advanced tumor stage, postoperative pulmonary complications, and certain treatment modalities significantly influence the outcomes in elderly esophagectomy patients. These findings provide critical insights into the characteristics and outcomes of this patient population.

Comparing 90-Day Postoperative Mortality After Neoadjuvant Proton-Based Versus Photon-Based Chemoradiotherapy for Esophageal Cancer

Purpose

Evidence suggests that proton-beam therapy (PBT) results in less toxicity and postoperative complications compared to photon-based radiotherapy in patients who receive chemoradiotherapy followed by esophagectomy for cancer. Ninety-day mortality (90DM) is an important measure of the postoperative (nononcologic) outcome as proxy of quality-of-care. We hypothesize that PBT could reduce 90DM compared to photon-based radiotherapy.

Materials and Methods

From a single-center retrospective database patients treated with chemoradiotherapy before esophagectomy for cancer were selected (1998-2022). Univariable logistic regression was used to study the association of radiotherapy modality with 90DM. Three separate methods were applied to adjust for confounding bias, including multivariable logistic regression, propensity score matching, and inverse probability of treatment weighting. Stratified analysis for the age threshold that maximized the difference in 90DM (ie, ≥67 vs <67 years) was performed.

Results

A total of 894 eligible patients were included and 90DM was 5/202 (2.5%) in the PBT versus 29/692 (4.2%) in the photon-based radiotherapy group (P = .262). After adjustment for age and tumor location, PBT versus photon-based radiotherapy was not significantly associated with 90DM (P = .491). The 90DM was not significantly different for PBT versus photon-based radiotherapy in the propensity score matching (P = .379) and inverse probability of treatment weighting cohort (P = .426). The stratified analysis revealed that in patients aged ≥67 years, PBT was associated with decreased 90DM (1.3% vs 8.8%; P = .026). Higher age significantly increased 90DM risk within the photon-based radiotherapy (8.8% vs 2.7%; P = .001), but not within the PBT group (1.3% vs 3.2%; P = .651).

Conclusion

No statistically significant difference was observed in postoperative 90DM after esophagectomy for cancer between PBT and photon-based neoadjuvant chemoradiotherapy. However, among older patients a signal was observed that PBT may reduce 90DM risk.

The effect of aging on short- and long-term results after esophagectomy: an international multicenter retrospective analysis

The optimal treatment for esophageal cancer in elderly patients is still debated and data on postoperative results are limited. This retrospective international study aims to clarify the impact of age on clinical and oncological outcomes after esophagectomy. All patients that underwent esophagectomy for cancer between 2007 and 2016 at two European high-volume Centers have been included in the study. Patients were divided into three groups according to their age: young-age group (YAG) (18-69), middle-age group (70-74) and old-age group (>74). Primary outcome was 5-year overall survival (OS), while secondary outcomes considered were 5-year disease free survival and disease related survival, 90-day morbidity and mortality, readmission rate and radicality. A total of 575 patients were included. No differences emerged in terms of morbidity and length of stay, while mortality increased with aging from 2% in YAG to 4.8% in old-aged (P = 0.003). Old-age patients had less neoadjuvant treatment (P < 0.001), a less aggressive mediastinal lymphadenectomy and presented a more advanced pathological stage. As expected, OS decreased significantly for older patients compared with the other two age groups (P = 0.044) but, on the other hand, disease free and disease related survival were comparable between the groups. Age itself should not be considered a contraindication to esophagectomy. Although in patients older than 75 years postoperative mortality is significantly increased, esophagectomy could be still an option in selected patients, favoring the use of minimally invasive techniques and enhanced recovery protocols.

The feasibility of a "no tube, no fasting" fast-track recovery protocol after esophagectomy for esophageal cancer patients aged 75 and over

Objective

For elderly patients aged ≥75 with esophageal cancer, whether surgical treatment is safe and effective and whether it is feasible to use a relatively radical "no tube, no fasting" fast-track recovery protocol remain topics of debate. We conducted a retrospective analysis to shed light on these two questions.

Methods

We retrospectively collected the data of patients who underwent McKeown minimally invasive esophagectomy (MIE) combined with early oral feeding (EOF) on postoperative day 1 between April 2015 and December 2017 at Medical Group 1, Ward 1, Department of Thoracic Surgery of our hospital. Preoperative characteristics, postoperative complications, operation time, intraoperative blood loss, duration of anastomotic leakage (day), hospital stay, and survival were evaluated.

Results

Twenty-three elderly patients with esophageal cancer underwent surgery with EOF. No significant difference was observed in intraoperative measures. The incidence of postoperative complications was 34.8% (8/23). Two patients (8.7%) were terminated early during the analysis of the feasibility of EOF. For all 23 patients, the mean hospital stay was 11.4 (5-42) days, and the median survival was 51 months.

Conclusion

Patients aged ≥75 with resectable esophageal cancer can achieve long-term survival with active surgical treatment. Moreover, the "no tube, no fasting" fast-track recovery protocol is safe and feasible for elderly patients.

Minimally invasive Ivor Lewis esophagectomy in the elderly patient: a multicenter retrospective matched-cohort study

Introduction

Several studies reported the advantages of minimally invasive esophagectomy over the conventional open approach, particularly in terms of postoperative morbidity and mortality. The literature regarding the elderly population is however scarce and it is still not clear whether elderly patients may benefit from a minimally invasive approach as the general population. We sought to evaluate whether thoracoscopic/ laparoscopic (MIE) or fully robotic (RAMIE) Ivor-Lewis esophagectomy significantly reduces postoperative morbidity in the elderly population.

Methods

We analyzed data of patients who underwent open esophagectomy or MIE/RAMIE at Mainz University Hospital and at Padova University Hospital between 2016 and 2021. Elderly patients were defined as those ≥ 75 years old. Clinical characteristics and the postoperative outcomes were compared between elderly patients who underwent open esophagectomy or MIE/RAMIE. A 1-to-1 matched comparison was also performed. Patients < 75 years old were evaluated as a control group.

Results

Among elderly patients MIE/RAMIE were associated with a lower overall morbidity (39.7% vs. 62.7%, p=0.005), less pulmonary complications (32.8 vs. 56.9%, p=0.003) and a shorter hospital stay (13 vs. 18 days, p=0.03). Comparable findings were obtained after matching. Similarly, among < 75 years-old patients, a reduced morbidity (31.2% vs. 43.5%, p=0.01) and less pulmonary complications (22% vs. 36%, p=0.001) were detected in the minimally invasive group.

Discussion

Minimally invasive esophagectomy improves the postoperative course of elderly patients reducing the overall incidence of postoperative complications, particularly of pulmonary complications.

Real-world management and outcomes of older patients with locally advanced esophageal squamous cell carcinoma: a multicenter retrospective study

Background

Neoadjuvant chemotherapy (NAC) followed by surgery is the standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). Chemoradiotherapy (CRT) is an alternative treatment approach. However, both treatments are associated with toxicity, and the optimal treatment for older patients with ESCC is unknown. This study aimed to evaluate the treatment strategies and prognosis of older patients with locally advanced ESCC in a real-world setting.

Methods

We retrospectively evaluated 381 older patients (≥ 65 years) with locally advanced ESCC (stage IB/II/III, excluding T4) who received anticancer therapy at 22 medical centers in Japan. Based on age, performance status (PS), and organ function, the patients were classified into two groups: clinical trial eligible and ineligible groups. Patients aged ≤ 75 years with adequate organ function and a PS of 0–1 were categorized into the eligible group. We compared the treatments and prognoses between the two groups.

Results

The ineligible group had significantly shorter overall survival (OS) than the eligible group (hazard ratio [HR] for death, 1.65; 95% confidence interval [CI], 1.22–2.25; P = 0.001). The proportion of patients receiving NAC followed by surgery was significantly higher in the eligible group than in the ineligible group (P = 1.07 × 10–11), whereas the proportion of patients receiving CRT was higher in the ineligible group than in the eligible group (P = 3.09 × 10–3). Patients receiving NAC followed by surgery in the ineligible group had comparable OS to those receiving the same treatment in the eligible group (HR, 1.02; 95% CI, 0.57–1.82; P = 0.939). In contrast, patients receiving CRT in the ineligible group had significantly shorter OS than those receiving CRT in the eligible group (HR, 1.85; 95% CI, 1.02–3.37; P = 0.044). In the ineligible group, patients receiving radiation alone had comparable OS to those receiving CRT (HR, 1.13; 95% CI, 0.58–2.22; P = 0.717).

Conclusions

NAC followed by surgery is justified for select older patients who can tolerate radical treatment, even if they are old or vulnerable to enrollment in clinical trials. CRT did not provide survival benefits over radiation alone in patients ineligible for clinical trials, suggesting the need to develop less-toxic CRT.

Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis

BACKGROUND

Older adults have unique needs for supportive care after surgery. We examined symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults.

PATIENTS AND METHODS

We conducted a population-level study of patients ≥ 70 years old undergoing cancer surgery (2007-2018) using prospectively collected Edmonton Symptom Assessment System (ESAS) scores. The monthly prevalence of moderate to severe symptoms (ESAS ≥ 4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor wellbeing was computed over 12 months after surgery.

RESULTS

Among 48,748 patients, 234,420 ESAS scores were recorded over 12 months after surgery. Moderate to severe tiredness (57.8%), poor wellbeing (51.9%), and lack of appetite (39.3%) were most common. The proportion of patients with moderate to severe symptoms was stable over the 1 month prior to and 12 months after surgery (< 5% variation for each symptom). There was no clinically significant change (< 5%) in symptom trajectory with the initiation of adjuvant therapy.

CONCLUSIONS

Patient-reported symptom burden was stable for up to 1 year after cancer surgery among older adults. Neither surgery nor adjuvant therapy coincided with a worsening in symptom burden. However, the persistence of symptoms at 1 year may suggest gaps in supportive care for older adults. This information on symptom trajectory and predictors of high symptom burden is important to set appropriate expectations and improve patient counseling, recovery care pathways, and proactive symptom management for older adults after cancer surgery.

Neoadjuvant versus definitive chemoradiation in locally advanced esophageal cancer for patients of advanced age or significant comorbidities

The addition of surgery to chemoradiation for esophageal cancer has not shown a survival benefit in randomized trials. Patients with more comorbidities or advanced age are more likely to be given definitive chemoradiation due to surgical risk. We aimed to identify subsets of patients in whom the addition of surgery to chemoradiation does not provide an overall survival (OS) benefit. The National Cancer Database was queried for patients with locally advanced esophageal cancer who received either definitive chemoradiation or neoadjuvant chemoradiation followed by surgery. Bivariate analysis was used to assess the association between patient characteristics and treatment groups. Log-rank tests and Cox proportional hazards models were performed to assess for differences in survival. A total of 15,090 with adenocarcinoma and 5,356 with squamous cell carcinoma met the inclusion criteria. Patients treated with neoadjuvant chemoradiation and surgery had significantly improved survival by Cox proportional hazards model regardless of histology if <50, 50-60, 61-70, or 71-80 years old. There was no significant benefit or detriment in patients 81-90 years old. Survival advantage was also significant with a Charlson/Deyo comorbidity condition score of 0, 1, 2, and ≥3 in adenocarcinoma squamous cell carcinoma with scores of 2 or ≥3 had no significant benefit or detriment. Patients 81-90 years old or with squamous cell carcinoma and a Charlson/Deyo comorbidity score ≥ 2 lacked an OS benefit from neoadjuvant chemoradiation followed by surgery compared with definitive chemoradiation. Careful consideration of esophagectomy-specific surgical risks should be used when recommending treatment for these patients.

Impact of Age on the Treatment and Survival in Esophagogastric Cancer

BACKGROUND

The age-specific risks of mortality for patients with esophagogastric cancer and their probability of surgical treatment are not well-known.

METHODS

This population-based, nationwide cohort study included all patients with esophageal or gastric (esophagogastric) cancer in Sweden between 1990 and 2013, with follow-up evaluation throughout 2018. Age at diagnosis (exposure) was categorized into nine 5-year groups. The main outcome was 5-year all-cause mortality. The secondary outcomes were 90-day all-cause mortality, 5-year disease-specific mortality, 5-year disease-specific mortality excluding 90-day all-cause mortality, and non-operation. For mortality outcomes, Cox regression provided hazard ratios (HRs) with 95% confidence intervals (95% CIs) adjusted for confounders. For non-operation, logistic regression provided odds ratios (ORs) with 95% CIs.

RESULTS

Among 28,725 patients, 11,207 (39.0%) underwent surgery. For those who underwent surgery, the HRs of 5-year all-cause mortality were stable before the ages of 65 to 69 years. After that, it gradually increased for patients 65 to 69 years old (HR, 1.13; 95% CI, 1.01-1.26), patients 75 to 79 years old (HR, 1.29; 95% CI, 1.56-1.44), and patients older than 85 years (HR, 1.84; 95% CI, 1.60-2.11) compared with those younger than 50 years. Analyses of age as a continuous variable, other mortality outcomes and stratification by comorbidity and tumor type showed similar results. The odds of non-operation increased for patients 75 to 79 years old (OR, 2.09 [95% CI, 1.84-2.94] for patients 80 to 84 years old and OR, 5.00 [95% CI, 4.31-5.78] for patients ≥85 years old or older), compared with those younger than 50 years.

CONCLUSION

Older age, starting from 65 years, is associated with worse survival after surgery for esophagogastric cancer, and from 75 years with lower odds of surgical treatment.

Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis

BACKGROUND

Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults.

METHODS

Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home.

RESULTS

Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma).

CONCLUSIONS

Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.

Construction of survival prediction model for elderly esophageal cancer

Background

The purpose of this study was to analyze the clinical characteristics and prognosis of EPEC and to construct a prediction model based on the SEER database.

Methods

All EPECs from the SEER database were retrospectively analyzed. A comprehensive and practical nomogram that predicts the overall survival (OS) of EPEC was constructed. Univariate and multivariate Cox regression analysis was performed to explore the clinical factors influencing the prognosis of EPEC, and finally, the 1 -, 3 - and 5-year OS were predicted by establishing the nomogram. The discriminant and predictive ability of the nomogram was evaluated by consistency index (C-index), calibration plot, area under the curve (AUC), and receiver operating characteristic (ROC) curve. Decision curve analysis (DCA) was used to evaluate the clinical value of the nomogram.

Results

A total of 3478 patients diagnosed with EPEC were extracted from the SEER database, and the data were randomly divided into the training group (n=2436) and the validation group (n=1402). T stage, N stage, M stage, surgery, chemotherapy, radiotherapy, age, grade, and tumor size were independent risk factors for 1 -, 3 - and 5-year OS of EPEC (P< 0.05), and these factors were used to construct the nomogram prediction mode. The C-index of the validation and training cohorts was 0.718 and 0.739, respectively, which were higher than those of the TNM stage system. The AUC values of the nomogram used to predict 1-, 2-, and 3-year OS were 0.751, 0.744, and 0.786 in the validation cohorts (0.761, 0.777, 0.787 in the training cohorts), respectively. The calibration curve of 1-, 2-, and 3-year OS showed that the prediction of the nomogram was in good agreement with the actual observation. The nomogram exhibited higher clinical utility after evaluation with the 1-, 2-, and 3-year DCA compared with the AJCC stage system.

Conclusions

This study shows that the nomogram prediction model for EPEC based on the SEER database has high accuracy and its prediction performance is significantly better than the TNM staging system, which can accurately and individually predict the OS of patients and help clinicians to formulate more accurate and personalized treatment plans.

Esophageal cancer: Outcome and potential benefit of esophagectomy in elderly patients

Background

This analysis evaluated the morbimortality and the potential benefit of esophagectomy for cancer in elderly patients.

Methods

Patients who underwent esophagectomy for EC were divided into elderly (≥70 years) and nonelderly (<70 years) groups. The groups were compared regarding patient and tumor characteristics, postoperative morbimortality, and disease‐free, overall and cancer‐specific survival.

Results

Sixty‐one patients were classified into elderly, and 187 into nonelderly groups. The elderly were characterized by a higher rate of WHO score (p < 0.0001), higher cardiac (p < 0.004) and renal (p < 0.023) comorbidities.

The rate of neoadjuvant therapy and especially of neoadjuvant CRT was significantly lower in elderly patients (p < 0.018 and p < 0.007). Operative morbidity was also higher in this group (p < 0.024).

The 30‐ and 90‐day mortality was 8.2 and 11.5%, respectively in elderly patients and 0.5 and 3.2% in nonelderly patients (p < 0.004 and p < 0.012). This 90‐day mortality decreased when specific surgery‐related deaths were taken into consideration. OS and DFS were significantly better in the nonelderly group (p < 0.003 and p < 0.005) while no difference was observed for cancer‐specific survival (CSS).

Conclusion

No difference in CSS was observed. Although elderly patients with EC had higher postoperative morbimortality, the age should not be a criterion whether to perform, or not to perform, esophagectomy. This decision must be based on the balance between the patient's general condition and aggressive disease.

Prognostic Value of Carcinoembryonic Antigen Changes Before and After Operation for Esophageal Squamous Cell Carcinoma

BACKGROUND

To study the prognostic significance of changes in the level of carcinoembryonic antigen (CEA) before and after surgery on the long-term prognosis of patients with esophageal squamous cell carcinoma (ESCC).

METHODS

Patients with ESCC who underwent radical esophagectomy (between 2010 and 2017) were divided into three groups as follows: normal group (preoperative CEA≦1.6 ng/ml), normalized group (preoperative CEA > 1.6 ng/ml and postoperative CEA≦1.6 ng/ml) and non-normalized group (preoperative CEA > 1.6 ng/ml and postoperative CEA > 1.6 ng/ml). The Kaplan-Meier analysis was used to construct survival curves. Cox proportional hazards regression models was used to determine the independent prognostic factors for ESCC. Variables with P < 0.1 in univariable analysis were included in the multivariable model used to determine the independent risk factors.

RESULTS

A total of 394 patients were included. The 5-OS rate of ESCC patients in normalized group (n = 36) and non-normalized group (n = 161) were significantly shorter than normal group (n =197) patients (57.3% vs 58.3% vs 82.0%, P < 0.001). The difference in survival time distribution between normal group and normalized/non-normalized group is statistically significant, P < 0.001. However, there was no statistically significant variation in survival time distribution between the normalized and non-normalized groups, P = 0.289. In multivariate analysis, older age (> 65 years old), advanced pT-stage, advanced pN-stage, normalized group and non-normalized group were independent prognostic risk factors of worse overall survival.

CONCLUSIONS

ESCC patients with high preoperative CEA level had poorer prognosis regardless of the changes of postoperative CEA level.

Oncological liver resection in elderly - A retrospective comparative study

BACKGROUND

Due to demographic changes and higher life expectancy especially in industrial nations, the number of liver resections in patients ≥70 years is rising. It is known that older age is associated with higher postoperative morbidity and mortality after surgery under general anesthesia. The aim of this analysis is to compare the postoperative outcome after liver resections for malignancies in patients aged below and above 70 years.

MATERIALS AND METHODS

A prospectively collected electronic database of 1034 liver resections between 01/2013 and 12/2019 was retrospectively analyzed. Comparative analysis of patients <70 and ≥ 70 years receiving liver resections for malignancies included 889 operations in 703 patients. Analysis of postoperative outcome and uni- and multivariate analyses of associated risk factors were performed.

RESULTS

Median age of the whole cohort was 65 years (range 18-87 years). N = 582 liver resections (65.7%) were performed in patients <70 years with 42.8% major hepatectomies and n = 307 (34.3%) liver resections in patients ≥70 years with 50.5% major hepatectomies (p = 0.034). Relevant postoperative morbidity of the whole cohort was 27.9%. The 30-day mortality was 3.9% and re-operation rate 14.8%. Patients ≥70 years had significantly higher postoperative morbidity and mortality rates than patients <70 years. Major resections, longer operating time, need of intraoperative transfusions of blood products as well as biliodigestive anastomosis (BDA) and inferior vena cava (IVC) resection were independent risk factors for worse postoperative outcome.

CONCLUSION

Liver resections in patients ≥70 years are associated with a worse postoperative course after. Parenchyma sparing resections should be preferred in those patients.

Management of elderly patients with esophageal squamous cell cancer

This review focuses on the treatment about elderly esophageal cancer to clarify the current situation regarding our clinical question. Although there are several reviews about elderly esophageal cancer treatment, there are fundamental differences between Japan and the rest of the world. Two main differences are raised: histological differences and treatment strategies for resectable patients. We overview each status according to following clinical questions. First, there are no established evaluation criteria for frail. Second, selection criteria for surgery or non-surgery are not established. Third, few specific treatments for elderly patients (EPs) are investigated. In conclusion, there are many reports about treatment of esophageal squamous cell carcinoma for EPs, although treatment strategy is still controversial. We have to consider well-designed prospective trial to confirm specific treatment strategy according to each stage.

Treatment Patterns and Outcomes of Elderly Patients With Potentially Curable Esophageal Cancer

Objectives

The proportion of elderly patients with esophageal cancer (EC) is increasing due to prolonged life expectancy and aging process. The aim of the study is to explore the optimal treatment strategy for elderly patients (aged ≥70 years) with locally advanced EC.

Methods

Eligible patients with cT2-4aNxM0 EC were identified in the Surveillance, Epidemiology, and End Results database from 2010 to 2016. Treatment patterns were divided into six groups: surgical resection (S), chemoradiotherapy (CRT), trimodality therapy (CRT+S), radiotherapy (RT), chemotherapy (CT), or observation with no treatment (Obs). Survival between groups was compared using the log-rank test, and the Cox proportional hazards model was used to identify factors associated with overall survival (OS).

Results

A total of 2917 patients with potentially curable EC were identified. Of all the patients included, 6.7%, 51.8%, 18.0%, 9.4% and 3.6%received S, CRT, CRT+S, RT, and CT, respectively, whereas 10.6% underwent Obs. The 3-year OS estimates were 30.2% (95% confidence interval [CI]: 23.5–38.9%), 25.4% (95% CI: 22.8–28.3%),44.3% (95% CI: 39.3–49.9%), 11.4% (95% CI: 7.7–17.0%), 16.1% (95% CI: 9.1–28.3%), and 5.6% (95% CI: 3.2–9.8%) for S, CRT, CRT+S RT, CT, and Obs (p<0.001), respectively. Overall, patents underwent CRT+S had the longest OS, compared to other treatment patterns, and the survival difference was not significant between patients receiving CRT and S (p=0.12) in the elderly population. However, the survival benefits of trimodality therapy over CRT gradually weakened with the increase in age, and became statistically non-significant for EC patients aged ≥80 years (p=0.35). Multivariate analysis showed that treatment patterns, age, sex, tumor grade, T stage, N stage, and marital status were significantly associated with OS.

Conclusion

Generally, the use of trimodality therapy was associated with the longest OS, the survival benefits were comparable between CRT and S alone, and CRT was superior to RT or CT alone in elderly patients with curable EC. For patients intolerable to surgery or aged ≥80 years, definitive CRT should be considered as a preferable option.

Burden of esophageal cancer and its attributable risk factors in 204 countries and territories from 1990 to 2019

BACKGROUND

Esophageal cancer is a global health concern. Regularly updated data about the burden of esophageal cancer are essential for formulating specific public policies. We aimed to estimate the global, regional, and national burden and trends of esophageal cancer and its attributable risk factors from 1990 to 2019, by age, sex and socio-demographic index (SDI).

METHODS

Data about the incidence, death, disability-adjusted life-years (DALYs), and age-standardized rates were collected from Global Burden of Disease study 2019. Estimated annual percentage changes were used to quantify the temporal trends of age-standardized rates. Moreover, the risk factors attributable to esophageal cancer deaths were also presented.

RESULTS

There were 534,563 incident cases and 498,067 deaths in 2019, contributing to 11,666,017 DALYs. The absolute numbers of incidence, death, and DALYs had increased from 1990 to 2019, contrasting with declined changes in their corresponding age-standardized rates. The burden of esophageal cancer varied across different regions and countries, and the age-standardized rates were negative with SDI. Almost half of the esophageal cancer was concentrated in China. Males accounted for most of the burden of esophageal cancer, and the onset age tended to be older. The death of esophageal cancer was primarily attributable to smoking, followed by alcohol use, high body mass index, diet low in fruits and diet low in vegetables.

CONCLUSION

The burden of esophageal cancer was heterogeneous across regions and countries by sex, age, and SDI, providing information for governments that may help to formulate more targeted policies.

The effect of age on short-term and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy: a propensity score-matched analysis

Background

The number of elderly patients diagnosed with esophageal cancer rises. Current information about outcomes in elderly patients undergoing thoracoscopic Ivor Lewis esophagectomy is limited. The objective of this study was to evaluate the influence of age on short-and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy.

Methods

A retrospective review of 188 patients with esophageal cancer undergoing thoracoscopic Ivor Lewis esophagectomy between August 2014 and July 2019 was performed. Patients were divided into patients aged > 75 years (elderly group (EG), n = 37) and patients ≤ 75 years (younger group (YG), n = 151) and matched using propensity-score matching. Baseline characteristics, length of hospital stay, mortality and major postoperative complications (Clavien-Dindo ≥ grade III) were compared.

Results

After matching 74 patients remained (n = 37 in each group). Postoperatively, no significant differences in major and overall complications, intra-hospital and 30-day mortality, disease-free or overall survival up to 3 years after surgery were noted. The incidence of pulmonary complications (65% vs. 38%) and pneumonia (54% vs. 30%) was significantly higher and the median hospital length of stay (12 vs. 14 days) significantly longer in the EG versus YG.

Conclusion

Thoracoscopic Ivor Lewis esophagectomies resulted in acceptable postoperative major morbidity and mortality without compromising 3-years overall and disease-free survival in elderly compared to younger patients with esophageal cancer. However, the incidence of postoperative pulmonary complications was higher in patients aged over 75 years.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01435-5.

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.

Association of frailty with 90-day postoperative mortality & geriatric comanagement among older adults with cancer

INTRODUCTION

Geriatric medical comanagement of older surgical patients with cancer is associated with lower 90-day postoperative mortality. Here, we investigate the hypothesis that this association varies on the basis of the degree of a patient's frailty.

METHODS

Frailty was assessed using the Memorial Sloan Kettering Frailty Index. Our hypothesis was evaluated using two approaches, both adjusted for age, sex, American Society of Anesthesiologists Physical Status, preoperative albumin, operating room duration, and estimated blood loss. A logistic regression was performed with 90-day mortality as the outcome and geriatric comanagement, continuous Memorial Sloan Kettering Frailty Index, and an interaction term between these two variables as the primary predictors. We then categorized frailty into four levels and, within each level, performed logistic regression with geriatric comanagement as the primary predictor and 90-day mortality as the outcome. Finally, we extracted the effect size and used a meta-analytic approach to test for heterogeneity.

RESULTS

Of 1687 patients aged ≥75 years who underwent elective cancer surgery with a length of stay of ≥1 day, 931 (55%) received comanagement; 31 patients (3.3%) who received comanagement died within 90 days, compared with 72 (9.5%) who did not. Ninety-day mortality was not statistically significantly different by degree of frailty in either analysis (interaction P = 0.4; test of heterogeneity P = 0.8).

CONCLUSION

Geriatric comanagement is valuable for all older surgical patients, not just the frail, and should be provided to as large a portion of the older surgical population as possible. Further research should examine predictors of response to geriatric comanagement.

Neoadjuvant chemoradiotherapy followed by resection for esophageal cancer: clinical outcomes with the 'CROSS-regimen' in daily practice

BACKGROUND AND OBJECTIVES

Since the first results of the Dutch randomized CROSS-trial, neoadjuvant chemoradiotherapy (CRT) using carboplatin and paclitaxel followed by resection for primary resectable nonmetastatic esophageal cancer (EC) has been implemented as standard curative treatment in the Netherlands. The purpose of this retrospective study is to evaluate the clinical outcomes of this treatment in daily practice in a large academic hospital.

METHODS

Medical records of patients treated for primary resectable nonmetastatic EC between May 2010 and December 2015 at our institution were reviewed. Treatment consisted of five weekly courses of carboplatin (area under the curve 2) and paclitaxel (50 mg/m2) with concurrent external beam radiotherapy (23 fractions of 1.8 Gy), followed by transthoracic or transhiatal resection. Data on survival, progression, acute and late toxicity were recorded.

RESULTS

A total of 145 patients were included. Median follow-up was 43 months. Median overall survival (OS) and progression-free survival (PFS) were 35 (95% confidence interval [CI] 29.8-40.2) and 30 (95% CI 19.7-40.3) months, respectively, with corresponding 3-year OS and PFS of 49.6% (95% CI 40.4-58.8) and 45.6% (95% CI 36.6-54.6). Acute toxicity grade ≥3 was observed in 25.5% of patients. Late adverse events grade ≥3 were seen in 24.8%, mostly esophageal stenosis.

CONCLUSION

Neoadjuvant CRT followed by resection for primary resectable nonmetastatic EC in daily practice results in a 3-year OS of 49.6% (95% CI 40.4-58.8) and PFS of 45.6% (95% CI 36.6-54.6), compared with 58% (51-65%) and 51% (43-58%) within the CROSS-trial. The slightly poorer survival in our daily practice group might be due to the presence of less favorable patient and tumor characteristics in daily practice, as is to be expected in daily practice. Toxicity was comparable with that in the CROSS-trial and considered acceptable.

Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer

Importance

Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions.

Objective

To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes.

Design, Setting, and Participants

In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.

Exposures

Esophageal resection for cancer of the esophagus and gastroesophageal junction.

Main Outcomes and Measures

All-cause postoperative 90-day mortality.

Results

A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort.

Conclusions and Relevance

In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

Feasibility of esophagectomy for esophageal cancer in elderly patients: a case-control study

PURPOSE

Surgery in elderly patients with esophageal cancer is challenging due to high mortality and limited survival. This study aimed to evaluate the safety and effectiveness of curative esophagectomy in elderly patients with esophageal cancer.

METHODS

This study included 77 and 112 patients with esophageal cancer aged ≥ 70 and 40-64 years, respectively, who underwent R0 esophagectomy between January 1998 and December 2016. Patient characteristics, intraoperative outcomes, postoperative complications, and long-term survival were compared.

RESULTS

The proportions of comorbid diseases (85.7% vs. 57.1%; P < 0.001), the American Society of Anesthesiologists score (1/2/3; 2.6%/94.8%/2.6% vs. 42.9%/57.1%/0%; P < 0.001), the preoperative systemic inflammation score (SIS) (0/1/2; 20.8%/48.1%/31.2% vs. 38.4%/38.4%/23.2%; P = 0.036), and postoperative complications (Clavien-Dindo grade ≥ III) (33.8% vs. 20.5%; P = 0.041) were significantly higher in the elderly group than those in the non-elderly group. However, long-term overall survival (OS) and relapse-free survival were not significantly different between the groups. On multivariate analysis, SIS (hazard ratio, 3.06; P = 0.037) and severe postoperative complications (hazard ratio, 2.01; P = 0.039) were significantly correlated with OS in the elderly group.

CONCLUSIONS

As SIS and severe postoperative complications lead to poor prognosis after R0 esophagectomy in elderly patients, selecting appropriate patients for esophagectomy and preventing severe postoperative complications is essential.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An NCDB Analysis

INTRODUCTION

Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer.

METHODS

We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model.

RESULTS

A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281).

CONCLUSIONS

Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Metastasis Patterns and Prognosis of Elderly Patients With Esophageal Adenocarcinoma in Stage IVB: A Population-Based Study

Background

Esophageal adenocarcinoma (EAC) is the most common kind of esophageal cancer. Age at diagnosis of advanced EAC is greater. Studies about practice patterns for elderly EAC patients with distant metastasis (DM) in stage IVB are limited. This retrospective, population-based study was conducted using data from the Surveillance, Epidemiology, and End Results (SEER) to evaluate 855 elderly EAC patients with DM in stage IVB from 2010 to 2015.

Methods

855 elderly EAC patients with DM in stage IVB between 2010 and 2015 were included in this study. Univariate and multivariate Cox-regression and Kaplan-Meier analyses were used to assess prognosis. These patients were classified to bone-only, brain-only, lung-only, liver-only, and multiple (patients with two or more organs in metastasis)-site group according to the site of metastasis. Overall survival (OS), cancer-specific survival (CSS), median survival time (MST), and survival rate (SR) were evaluated to analyze the survival outcomes.

Results

The most common metastasis site was the liver among the single-organ metastasis population, followed by lung, bone, and brain. Compared with the bone-only group, the multiple-site group was associated with worst OS (HR: 1.037, 95% CI: 0.811–1.327, p = 0.770) and CSS (HR: 1.052, 95% CI: 0.816–1.357, p = 0.695). The multiple-site group also had the lowest MST in the population (MST: 2 months in OS and 3 months in CSS) and SR (6-month SR: 27.1% in OS, 29.9% in CSS, 1-year SR: 10.7% in OS, 12.0% in CSS, 3-year SR: 2.5% in OS, 2.8% in CSS). Compared to untreated patients (N) in the total population, other patients who were treated with surgery (S), radiotherapy (R), and chemotherapy (C) are beneficial for the prognosis (OS and CSS: p < 0.001).

Conclusion

This population-based study was conducted to ascertain metastasis patterns and survival outcomes of EAC patients with DM in stage IVB. Elderly patients with multiple-site metastasis exhibited the worst OS and CSS among all the populations, and patients with bone-only metastasis had the worst OS and CSS among single-organ metastasis populations. Active treatment is beneficial for elderly EAC patients with DM in stage IVB, especially chemotherapy. This study also shows that more than one third of the patients had not received any therapy.

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.

Association of frailty with long-term homecare utilization in older adults following cancer surgery: Retrospective population-based cohort study

INTRODUCTION

Frailty is an important prognostic factor, and the association with postoperative dependence is important outcome to older adults. We examined the association of frailty with long-term homecare utilization for older adults following cancer surgery.

METHODS

In this population-based cohort study, we determined frailty status in all older adults (≥70 years old) undergoing cancer resection (2007-2017). Outcomes were receipt of homecare and intensity of homecare (days per month) over 5 years. We estimated the adjusted association of frailty with outcomes, and assessed interaction with age.

RESULTS

Of 82,037 patients, 6443 (7.8%) had frailty. Receipt and intensity of homecare was greater with frailty, but followed similar trajectories over 5 years between groups. Homecare receipt peaked in the first postoperative month (51.4% frailty, 43.1% no frailty), and plateaued by 1 year until 5 years (28.5% frailty, 12.8% no frailty). After 1 year, those with frailty required 4 more homecare days per month than without frailty (14 vs 10 days/month). After adjustment, frailty was associated with increased homecare receipt (hazard ratio 1.40; 95%CI 1.35-1.45), and increasing intensity each year (year 1 incidence rate ratio [IRR] 1.22, 95%CI 1.18-1.27 to year 5 IRR 1.47, 95%CI 1.35-1.59). The magnitude of the association of frailty with homecare receipt decreased with age (p_interaction <0.001).

CONCLUSION

While the trajectory of homecare receipt and intensity is similar between those with and without frailty, frailty is associated with increased receipt of homecare and increased intensity of homecare after cancer surgery across all age groups.

Elderly patients have increased perioperative morbidity and mortality from oesophagectomy for oesophageal cancer: A systematic review and meta-analysis

BACKGROUND

Although oesophagectomy remains technically challenging and associated with high morbidity and mortality, it is now increasingly performed in an ever-ageing population with improvement in perioperative care. However, the risks in the elderly population are poorly quantified. The study aims to review the current evidence to quantify further the postoperative risk of oesophagectomy for cancer in the elderly population compared to younger patients.

METHOD

A systematic literature search of PubMed, EMBASE and the Cochrane Library databases was conducted including studies reporting oesophagectomy for cancer in the elderly population. A meta-analysis was reported in accordance with the recommendations of the Cochrane Library and PRISMA guidelines. Primary outcome was overall complications and secondary outcomes were pulmonary and cardiac complications, anastomotic leaks, overall and disease-free survival.

RESULTS

This review identified 37 studies incorporating 30,836 patients. Increasing age was significantly associated with increased rates of overall complications (OR 1.67, CI_95%: 1.42-1.96), pulmonary complications (OR 1.87, CI_95%: 1.48-2.35), and cardiac complications (OR: 2.22, CI_95%: 1.95-2.53). However, there was no increased risk of anastomotic leak (OR: 0.98, CI_95%: 0.85-1.18). Elderly patients were significantly more likely to have lower rates of 5-year overall survival (OR: 1.36, CI_95%: 1.11-1.66) and 5-year disease-free survival (OR: 1.72, CI_95%: 1.51-1.96).

CONCLUSION

Elderly patients undergoing oesophagectomy for cancer are at increased risk of overall, pulmonary and cardiac complications, irrespective of age subgroups, albeit no difference in anastomotic leaks. Therefore, they represent high-risk patients warranting implementation of preoperative pathways such as prehabilitation to improve cardiopulmonary fitness prior to surgery, although benefit of prehabilitation is yet to be proven. This information will also aid future pre-operative counselling and informed consent.

Outcomes of curative esophageal cancer surgery in elderly: A meta-analysis

BACKGROUND

An increasing number of older patients is undergoing curative, surgical treatment of esophageal cancer. Previous meta-analyses have shown that older patients suffered from more postoperative morbidity and mortality compared to younger patients, which may lead to patient selection based on age. However, only studies including patients that underwent open esophagectomy were included. Therefore, it remains unknown whether there is an association between age and outcome in patients undergoing minimally invasive esophagectomy.

AIM

To perform a systematic review on age and postoperative outcome in esophageal cancer patients undergoing esophagectomy.

METHODS

Studies comparing older with younger patients with primary esophageal cancer undergoing curative esophagectomy were included. Meta-analysis of studies using a 75-year age threshold are presented in the manuscript, studies using other age thresholds in the Supplementary material. MEDLINE, Embase and the Cochrane Library were searched for articles published between 1995 and 2020. Risk of bias was assessed with the Newcastle-Ottawa Scale. Primary outcomes were anastomotic leak, pulmonary and cardiac complications, delirium, 30- and 90-d, and in-hospital mortality. Secondary outcomes included pneumonia and 5-year overall survival.

RESULTS

Seven studies (4847 patients) using an age threshold of 75 years were included for meta-analysis with 755 older and 4092 younger patients. Older patients (9.05%) had higher rates of 90-d mortality compared with younger patients (3.92%), (confidence interval = 1.10-5.56). In addition, older patients (9.45%) had higher rates of in-hospital mortality compared with younger patients (3.68%), (confidence interval = 1.01-5.91). In the subgroup of 2 studies with minimally invasive esophagectomy, older and younger patients had comparable 30-d, 90-d and in-hospital mortality rates.

CONCLUSION

Older patients undergoing curative esophagectomy for esophageal cancer have a higher postoperative mortality risk. Minimally invasive esophagectomy may be important for minimizing mortality in older patients.

The impact of age on patients undergoing transthoracic esophagectomy for cancer

To compare long-term and short-term outcomes in patients <70 years old with those ≥ 70 years old, who underwent transthoracic esophagectomy for carcinoma. With an ageing population more patients, with increasing co-morbidities are being diagnosed with potentially curable esophageal cancer. Concerns exist regarding offering older patients esophagectomy, conversely undue prejudice may exists that may prevent surgery being offered. Consecutive patients from a single unit between January 2000 and July 2016 that underwent trans-thoracic esophagectomy with or without neoadjuvant treatment for carcinoma were included. Short-term outcomes including morbidity, mortality, length of stay and long-term survival were compared between those <70 and those ≥ 70. This study identified 992 patients who underwent esophagectomy during the study period, of which 302 (30%) ≥ 70 years old. Greater proportion ≥ 70 years old had SCC (squamous cell carcinoma) (23%) than <70 (18%) (p = 0.07). Patients ≥ 70 years old were noted to have higher ASA Grade 3 (34% vs 25%, p = 0.004) and were less likely to receive neoadjuvant treatment (64% vs 45% p<0.001). Length of stay was longer in ≥ 70 (14 vs 17 days p<0.001), and there were more complications (63% vs 75% p<0.001). In hospital mortality was higher in ≥ 70 (2% vs 5% p = 0.026). Overall survival was 50 months in <70 vs 36 months in ≥ 70 (p = <0.001). In <70s with adenocarcinoma, overall survival was 52 months vs 35 months in the ≥ 70 (p<0.001). No significant difference in survival in patients with SCC, 49 months in <70 vs 54 months in ≥ 70 (p = 0.711). Increased peri-operative morbidity and mortality combined with the reduction in the long term survival in the over 70s cohort should be addressed when counselling patients undergoing curative resection for oesophageal cancer.

Patient-Centered Time-at-Home Outcomes in Older Adults After Surgical Cancer Treatment

Importance

Functional outcomes are central to cancer care decision-making by older adults.

Objective

To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure.

Design, Setting, and Participants

This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018.

Main Outcomes and Measures

The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used.

Results

A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time.

Conclusions and Relevance

This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.

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.

Immediate and Long-Term Health Care Support Needs of Older Adults Undergoing Cancer Surgery: A Population-Based Analysis of Postoperative Homecare Utilization

BACKGROUND

Functional outcomes are central to decision-making by older adults (OA), but long-term risks after cancer surgery have not been described beyond 1 year for this population. This study aimed to evaluate long-term health care support needs by examining homecare use after cancer surgery for OA.

METHODS

This population-based study investigated adults 70 years of age or older with a new cancer diagnosis between 2007 and 2017 who underwent resection. The outcomes were receipt and intensity of homecare from postoperative discharge to 5 years after surgery. Time-to-event analysis with competing events was used.

RESULTS

Among 82,037 patients, homecare use was highest (43.7% of eligible patients) in postoperative month 1. The need for homecare subsequently decreased to stabilize between year 1 (13.9%) and year 5 (12.6%). Of the patients not receiving preoperative homecare, 10.9% became long-term users at year 5 after surgery. Advancing age, female sex, frailty, high-intensity surgery, more recent period of surgery, and receipt of preoperative homecare were associated with increased hazards of postoperative homecare. Intensity of homecare went from 10.3 to 10.1 days per patient-month between month 1 and year 1, reaching 12 days per patient-month at year 5. The type of homecare services changed from predominantly nursing care in year 1 (51.9%) to increasing personal support services from year 2 (69.6%) to year 5 (77.5%).

CONCLUSION

Receipt of homecare increased long-term after cancer surgery for OA, peaking in the first 6 months and plateauing thereafter at a new baseline. One tenth of the patients without preoperative homecare became long-term homecare users postoperatively, indicating changing health care needs focused on personal support services from year 2 to year 5.

Proton beam therapy is a safe and effective treatment in elderly patients with esophageal squamous cell carcinoma

Background

There are many elderly patients with esophageal squamous cell carcinoma (ESCC). However, there are currently few articles regarding the clinical outcome following proton beam therapy in these patients. The purpose of this study was to evaluate the clinical results of proton beam therapy in elderly patients with ESCC.

Methods

Between January 2009 and December 2013, patients aged ≥75 years who underwent proton beam therapy were examined using multi‐institutional data from Japan.

Results

There were 38 inoperable patients (70.4%) and 16 operable patients (29.6%). More than 40% of patients had stage III/IV ESCC. The five‐year overall and cancer‐specific survival rates were 56.2% and 71.7%, respectively. Performance status was the only factor that significantly influenced overall survival during the multivariate analysis. The five‐year local control rate was 61.8%, and local recurrence occurred within 13 months in 82.4% of patients,. There was no grade 3 or higher toxicity, excluding three patients with grade 3 esophageal ulcers.

Conclusions

In conclusion, proton beam therapy may become an alternative treatment with lower toxicity in elderly patients with ESCC, compared to surgery or conventional X‐ray radiotherapy. This includes inoperable patients.

Key points

Significant findings of the study

Proton beam therapy was a safe and effective treatment for elderly patients with esophageal squamous cell carcinoma (ESCC) including inoperable patients.

What this study adds

Proton beam therapy may be a safer treatment choice for elderly patients with ESCC compared to conventional X‐ray radiotherapy.

Patient Age and Survival After Surgery for Esophageal Cancer

Background

Esophagectomy for esophageal cancer is associated with a substantial risk of life-threatening complications and a limited long-term survival. This study aimed to clarify the controversial questions of how age influences short-term and long-term survival.

Methods

This population-based cohort study included almost all patients who underwent curatively intended esophagectomy for esophageal cancer in Sweden in 1987–2010, with follow-up through 2016. The exposure was age, analyzed both as a continuous and categorical variable. The probability of mortality was computed using a novel flexible parametric model approach. The reported probabilities are proper measures of the risk of dying, and the related odds ratios (OR) are therefore more suitable measures of association than hazard ratios. The outcomes were 90-day all-cause mortality, 5-year all-cause mortality, and 5-year disease-specific mortality. A novel flexible parametric model was used to derive the instantaneous probability of dying and the related OR along with 95% confidence intervals (CIs), adjusted for sex, education, comorbidity, tumor histology, pathological tumor stage, and resection margin status.

Results

Among 1737 included patients, the median age was 65.6 years. When analyzed as a continuous variable, older age was associated with slightly higher odds of 90-day all-cause mortality (OR 1.05, 95% CI 1.02–1.07), 5-year all-cause mortality (OR 1.02, 95% CI 1.01–1.03), and 5-year disease-specific mortality (OR 1.01, 95% CI 1.01–1.02). Compared with patients aged < 70 years, those aged 70–74 years had no increased risk of any mortality outcome, while patients aged ≥ 75 years had higher odds of 90-day mortality (OR 2.85, 95% CI 1.68–4.84), 5-year all-cause mortality (OR 1.56, 95% CI 1.27–1.92), and 5-year disease-specific mortality (OR 1.38, 95% CI 1.09–1.76).

Conclusions

Patient age 75 years or older at esophagectomy for esophageal cancer appears to be an independent risk factor for higher short-term mortality and lower long-term survival.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08653-w) contains supplementary material, which is available to authorized users.

Clinical outcomes of oesophagectomy in elderly versus relatively younger patients: a meta-analysis

OBJECTIVES

The surgical efficacy of oesophagectomy for elderly patients (>80 years old) is still unclear. The aim of this meta-analysis was to compare the clinical outcomes of oesophagectomy between elderly and relatively younger patients.

METHODS

PubMed, EMBASE and the Cochrane Library were searched for relevant studies comparing the clinical outcomes of oesophagectomy for elderly and relatively younger patients. Odds ratios were extracted to obtain pooled estimates of the perioperative effect, and hazard ratios were extracted to compare survival outcomes between the 2 cohorts.

RESULTS

Nine studies involving 4946 patients were included in this meta-analysis. For patients older than 80 years of age, in-hospital mortality [odds ratio (OR) 2.00, 95% confidence interval (CI) 1.28-3.13; P = 0.002] and the incidence rates of cardiac (OR 1.55, 95% CI 1.10-2.20; P = 0.01) and pulmonary (OR 1.57, 95% CI 1.11-2.22; P = 0.01) complications were higher than those of relatively younger patients. The overall postoperative complication rate (OR 1.40, 95% CI 0.82-2.40; P = 0.22) and the incidence of anastomotic leak (OR 0.92, 95% CI 0.58-1.47; P = 0.73) were not significantly different between the 2 groups. Elderly patients had a worse overall 5-year survival rate (HR 2.66, 95% CI 1.65-4.28; P < 0.001) than that of relatively younger patients. The cancer-related 5-year survival rate of elderly patients was also lower than that of relatively younger patients (HR 3.37, 95% CI 2.36-4.82; P < 0.001).

CONCLUSIONS

Compared with relatively younger patients, elderly patients with oesophageal cancer undergoing oesophagectomy are at higher risk of in-hospital mortality and have lower survival rates. However, there is no conclusive evidence that the overall rate of complications is elevated in elderly patients.

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

The optimal treatment of esophageal cancer in octogenarians is controversial. While the safety of esophagectomy has been demonstrated in elderly patients, surgery and multimodality therapy are still offered to a select group. Additionally, the long-term outcomes in octogenarians have not been thoroughly compared to those in younger patients. We sought to compare the outcomes of esophageal cancer treatment between octogenarians and non-octogenarians in the National Cancer Database (2004-2014). The major endpoints were early postoperative mortality and long-term survival. A total of 107,921 patients were identified [octogenarian-16,388 (15.2%)]. Compared to non-octogenarians, octogenarians were more likely to be female, of higher socioeconomic status, and had more Charlson comorbidities (p < 0.001 for all). Octogenarians were significantly less likely to undergo esophagectomy (11.5% vs. 33.3%; p < 0.001) and multimodality therapy (2.0% vs. 18.5%; p < 0.001), a trend that persisted following stratification by tumor stage and Charlson comorbidities. Both 30-day and 90-day mortality were higher in the octogenarian group, even after multivariable adjustment (p ≤ 0.001 for both). Octogenarians who underwent multimodality therapy had worse long-term survival when compared to younger patients, except for those with stage III tumors and no comorbidities (HR: 1.29; p = 0.153). Within the octogenarian group, postoperative mortality was lower in academic centers, and the long-term survival was similar between multimodality treatment and surgery alone (HR: 0.96; p = 0.62). In conclusion, octogenarians are less likely to be offered treatment irrespective of tumor stage or comorbidities. Although octogenarians have higher early mortality and poorer overall survival compared to younger patients, outcomes may be improved when treatment is performed at academic centers. Multimodality treatment did not seem to confer a survival advantage compared to surgery alone in octogenarians, and more prospective studies are necessary to better elucidate the optimal treatment in this patient population.

Treatments and outcomes of older patients with esophageal cancer: Comparison with younger patients

The number of older patients with esophageal cancer (EC) is increasing due to the population aging and increasing life expectancy. However, no optimal treatment strategy for older patients with EC has been established to date. The aim of the present study was to review and compare the treatment modalities and outcomes of 990 younger and older patients diagnosed with EC in our institution. The patients were divided into younger (≤74 years) and older (≥75 years) groups. The majority of the patients in both groups had early-stage EC and were treated by endoscopic submucosal dissection (ESD). The older patients with locally advanced (stage II and III) EC were more likely to undergo chemoradiotherapy rather than esophagectomy. Among the older patients, 22% selected best supportive care. The disease-specific survival rate of the older patients was significantly lower compared with that of the younger patients, which was likely due to the less intense treatment modalities applied. The prognosis following esophagectomy was significantly better compared with that of chemoradiotherapy in the younger, but not in the older patients. In conclusion, the poorer prognosis of older patients (aged ≥75 years) with stage I EC may improve with multidisciplinary treatment after ESD. Although CRT is currently considered the optimal treatment for older patients with stage II/III EC, more efficient treatment modalities are urgently required.

A multicenter phase III study comparing Simultaneous Integrated Boost (SIB) radiotherapy concurrent and consolidated with S-1 versus SIB alone in elderly patients with esophageal and esophagogastric cancer - the 3JECROG P-01 study protocol

BACKGROUND

The importance of definitive radiotherapy for elderly patients with esophageal and esophagogastric-junction cancer is pronounced. However, little is known in terms of the best way to combine radiotherapy with other treatment options. This study aims to compare the efficiency of SIB radiotherapy alone with SIB radiotherapy concurrent and consolidated with S-1 for elderly patients. Comprehensive geriatric assessment is also incorporated in the procedure of treatment.

METHODS/DESIGN

The study is a two arm, open, randomized multicenter Phase III trial with patients over 70 years old with stage IIA-IVB (UICC 2002, IVB only with metastasis to supraclavicular or celiac lymph nodes) squamous cell carcinoma or adenocarcinoma of esophagus or gastroesophageal junction. A total of 300 patients will be randomized using a 1:1 allocation ratio stratified by disease stage and study site. Patients allocated to the SIB arm will receive definitive SIB radiotherapy (95%PTV/PGTV 50.4Gy/59.92Gy/28f) while those randomized to SIB + S-1 arm will receive definitive SIB radiotherapy concurrent and consolidated with S-1. The primary endpoint of the trial is 1-year overall survival. Secondary objectives include progression-free survival, recurrence-free survival (local-regional and distant), disease failure pattern, toxicity profile as well as quality of life. Besides, detailed radiotherapy protocol and quality assurance procedure have been incorporated into this trial.

DISCUSSION

The proportion of elderly patients in esophageal cancer is now growing, but there is a lack of evidence in term of treatment standard for this group of patients, which is what we aim to obtain through this prospective phase III study.

TRIAL REGISTRATION

clinicaltrials.gov NCT02979691 . Registered November 22, 2016.

The Influence of Age on Complications and Overall Survival After Ivor Lewis Totally Minimally Invasive Esophagectomy

BACKGROUND

The number of elderly patients suffering from esophageal cancer is increasing, due to an increasing incidence of esophageal cancer and increasing life expectancy. However, the effect of age on morbidity, mortality, and survival after Ivor Lewis total minimally invasive esophagectomy (TMIE) is not well known.

METHODS

A prospectively documented database from December 2010 to June 2017 was analyzed, including all patients who underwent Ivor Lewis TMIE for esophageal cancer in three Dutch high-volume esophageal cancer centers. Patients younger than 75 years (younger group) were compared to patients aged 75 years or older (elderly group). Baseline patient characteristics and perioperative data were included. Surgical complications were graded using the Clavien-Dindo scale. The primary outcome was postoperative complications Clavien-Dindo ≥ 3. Secondary outcome parameters were postoperative complications, in-hospital mortality, 30- and 90-day mortality and survival.

RESULTS

Four hundred and forty-six patients were included, 357 in the younger and 89 in the elderly group. No significant differences were recorded regarding baseline patient characteristics. There was no significant difference in complications graded Clavien-Dindo ≥ 3 and overall complications, short-term mortality, and survival. Delirium occurred in 27.0% in the elderly and 11.8% in the younger group (p < 0.001). After correction for baseline comorbidity this difference remained significant (p = 0.001). Median hospital length of stay was 13 days in the elderly and 11 days in the younger group (p = 0.010).

CONCLUSIONS

Ivor Lewis TMIE can be safely performed in selected elderly patients without increasing postoperative morbidity and mortality.

Oesophagectomy: The expanding role of minimally invasive surgery in oesophageal cancer

Historically, open oesophagectomy was the gold standard for oesophageal cancer surgery. This was associated with a relatively higher morbidity. In the last two decades, we have seen significant improvements in short and long term outcomes due to centralisation of oesophagectomy, multidisciplinary approach, enhanced recovery after surgery programmes, neoadjuvant treatments and advances in minimally invasive oesophagectomy (MIO) techniques. MIO has significantly reduced postoperative morbidity and improved functional recovery, while maintaining comparable long-term oncological outcomes. MIO is technically demanding, and requires a long learning curve. However, it has been proven to be safe and successful in expert centres. This is a review on the current role of MIO in the management of oesophageal cancer.

Evolution in the management of acute cholecystitis in the elderly: population-based cohort study

BACKGROUND

Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates.

METHODS

Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year.

RESULTS

47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy.

CONCLUSION

Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

Functional and cognitive impairment, social functioning, frailty and adverse health outcomes in older patients with esophageal cancer, a systematic review

BACKGROUND

Older patients with esophageal cancer are at high risk of adverse health outcomes, but the association of geriatric assessment with adverse health outcomes in these patients has not been systematically evaluated. The aim of this systematic review was to study the association of functional and cognitive impairment, social environment and frailty with adverse health outcomes in patients diagnosed with esophageal cancer.

METHODS

We searched Pubmed, Embase, Web of Science and Cochrane Library for original studies reporting on associations of functional or cognitive impairment, social environment and frailty with adverse outcomes (mortality, functional or cognitive decline, adverse events during treatment, prolonged length of hospitalization (LOS) and health related quality of life (HRQoL)) after follow-up in patients with esophageal cancer.

RESULTS

Of 1.391 identified citations, nineteen articles were included that reported on 53 associations. The median sample size of the included studies was 110 interquartile range (IQR 91-359). Geriatric conditions were prevalent: between 14 and 67% of the included participants were functionally impaired, around 42% had depressive symptoms and between 5 and 23% did not have a partner. In nineteen of 53 (36%) associations functional or cognitive impairment or frailty were significant associated with adverse health outcomes, but the studies were small. In four out of six (67%) associations with the largest sample size (n ≥ 359), functional impairment or social environment were significant associated with adverse health outcomes.

CONCLUSION

Functional and cognitive impairment, depression and social isolation are prevalent in patients with esophageal cancer, and associate with adverse health outcomes. Geriatric measurements may guide decision-making and customize treatments, but more large studies are needed to explore the clinical usability.

Postoperative outcomes of esophagectomy for cancer in elderly patients

BACKGROUND

The number of elderly patients with esophageal cancer is expected to increase. We aimed to determine the postoperative outcomes of esophagectomy for esophageal cancer in elderly patients.

MATERIAL AND METHODS

A retrospective, population-based analysis was performed using the National inpatient sample for the period 2000-2014. Adult patients ≥18 years old (yo) diagnosed with esophageal cancer who underwent esophagectomy during their inpatient hospitalization were included. Patients were categorized into <70 yo and ≥70 yo. Multivariable linear and logistic regressions were used to assess the potential effect of age on postoperative complications, inpatient mortality, and hospital charges.

RESULTS

Overall, 5243 patients were included, with 3699 (70.6%) <70 yo and 1544 (29.5%) ≥70 yo. The yearly rate of esophagectomies among patients ≥70 yo did not significantly changed during the study period (28.4% in 2000 and 26.3% in 2014, P = 0.76). Elderly patients were significantly more likely to have postoperative cardiac failure (odds ratio 1.59, 95% confidence interval [CI] 1.21, 2.09, P = 0.0009) and inpatient mortality (odds ratio 1.84, 95% CI 1.39, 2.45, P < 0.0001). Among the elderly patients, hospital charges were, on average, $16,320 greater (95% CI $3110, $29,530) than patients <70 yo (P = 0.02). The predicted probability of mortality increased consistently across age (1.5% in 40 yo, 2.5% in 50 yo, 3.6% in 60 yo, 5.4% in 70 yo, and 7.0% in 80 yo).

CONCLUSIONS

Elderly patients undergoing esophagectomy for cancer have a significantly higher risk of postoperative mortality and pose a higher financial burden on the health care system. Elderly patients with esophageal cancer should be carefully selected for surgery.