Resection for colorectal cancer in the very old: are the risks too high?

Surgery for colorectal cancer in elderly: a comparative analysis of risk factor in elective and urgency surgery

INTRODUCTION

Colon cancer therapy is primarily surgical. Advanced age does not represent a contraindication to surgery. We analyse the results of surgery in ultra 75 patients undergoing surgery for colorectal cancer by examining the correlation between the comorbidity and any post-operative complications.

MATERIALS AND METHODS

We surgically treated 66 patients for colorectal cancer, aged over 75. The examined subjects were compromised for various reasons. We have evaluated the different influences of risk factors in elective and urgency operation.

DISCUSSION

Several studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery. The assessment of general conditions in elderly patients, as demonstrated by the literature, is a fundamental moment in the management of colorectal cancer.

CONCLUSIONS

The surgical choice should be made case by case (custom-made), not based on age only.

The Application of Modern Diagnostic and Therapeutic Techniques to Aged Patients

The availability of high technology designed to preserve human life, places medical practitioners in a set of ethical dilemmas. In particular the use of Intensive Care Units to sustain acutely seriously ill elderly people is a matter of widespread debate. An examination of the medical research literature suggests that such interventions are largely successful and wished for by the patient, but the quality of surviving life is for some, unacceptable. It is concluded that the maintance of life should remain the predominant rule, but that where patient and clinical judgement indicates it, death should be accepted as the natural course.

Laparoscopic resection for colorectal cancer in octogenarians: results in a decade

OBJECTIVES

This study was designed to evaluate the results of laparoscopic resection for colorectal cancer in octogenarians.

METHODS

Patients aged 80 years or older who underwent elective laparoscopic resection for colorectal cancer from July 1, 1996 to June 30, 2006 were recruited for analysis, with the following exceptions: 1) patients who did not give informed consent; 2) unfit for operative treatment; 3) presented as surgical emergencies; 4) multiple previous abdominal operations; or 5) locally advanced tumors. Operating time, blood loss, length of hospital stay, mortality and morbidities, including anastomotic dehiscence, pulmonary and wound sepsis, disease recurrence, and patient survival were used to measure outcome.

RESULTS

During a ten-year period, laparoscopic colorectal cancer resection was attempted in 101 octogenarians. The median age was 83 (range, 80-95) years and 45 patients were males. The median operating time was 110 (range, 60-245) minutes, with a median blood loss of 50 (range, 0-1,000) ml. Conversion was required in only one case with a leakage rate of 3.3 percent. The overall morbidity and operative mortality rate were 17 and 3 percent, respectively. With a median follow-up of 24 (range, 0-102) months, 22 patients developed recurrence, with 8 of those still surviving. The overall five-year survival is 51 percent.

CONCLUSIONS

Our experience confirms that laparoscopic colorectal cancer resection in selected octogenarians is safe and feasible. Aside from the obvious short-term benefits, the long-term oncologic outcomes are favorable.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical advantages of laparoscopic colorectal cancer surgery in the elderly

BACKGROUND AND AIMS

Elderly patients have a high incidence of colorectal cancer, which may be associated with increased morbidity and mortality due to complex comorbidity and diminished cardiopulmonary reserves. The aims of this study were to compare the outcomes of laparoscopic colorectal cancer surgery with those observed in traditional open surgery in patients aged over 70 years.

METHODS

Between January 2003 and October 2004, 51 patients aged over 70 years with colorectal cancer, who underwent laparoscopic surgery (LAP group), were evaluated and compared with 102 controls (also over 70 years old) treated by traditional open surgery (OPEN group) in the same period. All patients were evaluated with respect to the American Society of Anesthesiologists (ASA) classification, surgery-related complications, and postoperative recovery.

RESULTS

No surgery-related death was observed in the LAP group, whereas two deaths occurred in the OPEN group for severe post-operative pulmonary infection and anastomotic leak, respectively. No pneumoperitoneum-related complications were observed in the LAP group; 2 (3.9%) patients required conversion to open surgery, because of the unexpectedly bulky tumor and severe adhesions in the abdominal cavity. With the increase in patients' age, increased ASA classification was observed. No significant differences were observed in gender, Dukes' staging or types of procedures between LAP and OPEN groups. The overall morbidity in the LAP group was significantly less than that of the OPEN group [17.6% (9/51) vs 37.3% (38/102), p=0.013]. Mean blood loss, time to flatus passage, and time to semi-liquid diet in the LAP group were significantly shorter than those of the OPEN group (90.7+/-49.9 vs 150.3+/-108.7 ml, 2.4+/-1.2 vs 3.5+/-2.9 d, 5.0+/-1.8 vs 5.9+/-1.2 d, respectively, p<0.05). No significant differences were observed in terms of mean operation time or hospital stay between LAP and OPEN groups.

CONCLUSION

Laparoscopic colorectal cancer surgery in elderly patients with colon cancer has clinically significant advantages over traditional open surgery, and appears to be the ideal surgical choice for the elderly.

Ventajas y peculiaridades del abordaje laparoscópico en el anciano

Both the age of the population and anesthetic and surgical techniques are advancing. Currently, 40% of surgical activity is performed in patients older than 65 years, who present a higher surgical risk than younger patients. The aim of treatment in the elderly is to provide the best possible quality of life, even though this represents a surgical challenge because of associated comorbidity and reduced cardiopulmonary reserve. From the moment at which laparotomy becomes an increased stress in the elderly, laparoscopic surgery can be particularly advantageous in this population. Therefore, minimally invasive surgery may have a greater impact in these individuals than in younger patients in reducing postoperative pain, cardiorespiratory complications, hospital stay, and recovery time before resuming physical activity. The recent advances in anesthesia, together with improved patient selection and perioperative cardiac care, and the general adoption of minimally invasive access have enabled more complex gastrointestinal procedures to be performed in the elderly. The factors that could influence the development of this type of approach in the elderly, as well as the precautions that should be taken, should be further analyzed.

Trends in the management and survival of digestive tract cancers among patients aged over 80 years

BACKGROUND

Advances have occurred in the management of digestive tract cancers, but it is not known how much they have benefited the elderly.

AIMS

To determine trends in treatment, stage at diagnosis and prognosis of digestive tract cancers among patients aged > or =80 years in two well-defined French populations.

DESIGN

Time trends were studied in three age classes and in 5 four-year time intervals. A multivariate relative survival analysis was performed to estimate the independent effect of both age and period on prognosis.

RESULTS

Five-year relative survival rates were 1.9% for oesophageal cancer, 12% for stomach cancer, 41% for colon cancer and 37% for rectal cancer. The survival rates improved between the first and the fifth period for all cancer sites except for oesophageal cancer. This improvement remained significant after adjustment for age, sex, site and treatment. It was associated with an increase in the proportion of patients who underwent curative resection. Very few patients received adjuvant chemotherapy. The use of adjuvant radiotherapy for rectal and oesophageal cancers did not significantly increase over time.

CONCLUSIONS

Except for oesophageal cancers, substantial advances in the care of digestive tract cancers in the elderly have been achieved. Surgery should not be restricted on the basis of age alone. Further improvements can be made in particular to enhance adjuvant therapy whenever possible.

Endoscopic transanal resection of rectal tumours using a urological resectoscope--still has a role in selected patients

INTRODUCTION

Transanal resection of rectal villous adenomas or adenocarcinomas can be carried out using various modalities such as operative excision, fulguration, laser coagulation or cryotherapy. Transanal endoscopic microsurgery is currently not widely available. Transanal resection can provide effective palliation for locally advanced rectal tumours in patients unfit for abdomino-perineal excision of rectum. A urological resectoscope can be safely and repeatedly used to resect advanced primary or locally recurrent rectal tumours by colorectal surgeons with urological expertise. This study reports our experience of treating rectal lesions with endoscopic transanal resection (ETAR) using the urological resectoscope.

METHODS

Patients were identified from one surgeons' prospectively collected operating data. Charts were retrieved and reviewed.

RESULTS

Over a 13-year period a total of 43 ETAR procedures were carried out in 20 patients (11 males; mean age 74 years; range 54-92 years) using the urological resectoscope. Twelve (60%) patients had a single resection; 8 (40%) patients required more than one resection; the mean number of procedures per patient was 2.2 (range 1-8). The median interval between resections for recurrent disease (excluding planned repeat resections) was 340 days (range 168-2337 days). Histopathology revealed rectal adenoma (with varying degrees of dysplasia) in 11 (55%) patients and adenocarcinoma in 9 (45%). The majority (30; 70%) of resections were carried out in patients with benign disease, with 13 (30%) in patients with rectal adenocarcinoma. Mean operating time per resection was 25 min. Thirteen (30%) resections were carried out under spinal anaesthetic. There was no procedure related mortality. There were no cases of haemorrhage, rectal perforation, 'TUR syndrome' or pelvic sepsis. No patients with benign disease subsequently developed an invasive carcinoma.

CONCLUSIONS

Accepting that this technique provides limited histopathological information regarding extent of resection and tumour clearance, our experience demonstrates that ETAR of rectal tumours using the urological resectoscope can provide a minimally invasive, effective and safe means of treating and palliating patients with benign and malignant rectal disease. There remains a place for this technique in selected patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluation of POSSUM and P-POSSUM scoring systems in patients undergoing colorectal surgery (Br J Surg 2003; 90: 340-345)

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Rectal cancer surgery in patients more than 80 years of age

BACKGROUND

This retrospective study aimed to compare the prognosis for rectal cancer in patients more than 80 years old with that observed in younger patients.

METHODS

Patients operated on for a rectal adenocarcinoma, from 1980 to 1998, were divided into two groups: group 1 (>80 years, n = 92); group 2 (<80 years, n = 276).

RESULTS

There were significant differences between the two groups with regard to the sex ratio, the American Society of Anesthesiologists (ASA) classification, the emergency presentation, and the curative operation rate. The operative mortality rate was 8% in group 1, 4% in group 2 (P = 0.26). The overall 5-year survival rate was 35% in group 1, 53% in group 2 (P = 0.0004). In patients operated on for cure, the cancer-specific 5-year survival rate was 50% in group 1, 59% in group 2 (P = 0.08).

CONCLUSIONS

The prognosis for rectal cancer in patients over 80 years is not significantly different from that of younger patients. Surgery should not be restricted on the basis of age.

Laparoscopic colorectal resection: a safe option for elderly patients

BACKGROUND

Open colorectal surgery in the elderly has been associated with higher morbidity and mortality rates. The favorable short-term outcomes of laparosocopic colorectal resection might reduce the morbidity in elderly patients. This study compares results of elderly patients (aged 70 and above) who underwent laparoscopic colorectal resection with those having open surgery.

STUDY DESIGN

Consecutive patients aged 70 and above who had elective colorectal resection from June 2000 to December 2001 were included. Data concerning demographics, diseases, details of operations, and postoperative events were collected prospectively. Comparisons between results of laparoscopic surgery and open surgery were made.

RESULTS

Sixty-five patients had laparoscopic colectomy and 89 had open surgery during the study period. Median ages were 77 years and 75 years in the open and laparoscopic groups, respectively. Presence of premorbid medical conditions, American Society of Anesthesiology score, and incidence of previous surgery were similar in the two groups. Median operative time was longer (180 minutes versus 135 minutes, p < 0.001), but blood loss was less (100 mL versus 200 mL, p = 0.001) in the laparoscopic group. Conversion to open surgery occurred in eight patients. One patient died in the laparoscopic group and five died in the open group. Laparoscopic resection was associated with earlier return of bowel function (3 days versus 4 days, p = 0.004), earlier resumption of solid diet (3 days versus 5 days, p < 0.001), shorter hospital stay (7 days versus 9 days, p = 0.001), and less cardiopulmonary morbidity (7.7% versus 22.4%, p = 0.033) when compared with open colorectal resection.

CONCLUSIONS

Laparoscopic colorectal resection is a safe option for elderly patients and is associated with more favorable short-term outcomes in terms of earlier return of bowel function, earlier resumption of diet, and shorter hospital stay. It is also associated with less cardiopulmonary morbidity, which is an important complication after colorectal surgery in the elderly.

Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer

Patients with metastatic rectal cancer precluding curative low anterior resection (LAR) or abdominoperineal resection (APR) can require palliation for impending obstruction. LAR or APR is frequently not optimal because of the associated operative morbidity. Lesser procedures such as diverting colostomy require patients to live with a permanent stoma. Endoscopic transanal resection (ETAR) has been used for excision of rectal lesions. To determine whether ETAR provides palliation equivalent to LAR or APR, we reviewed the outcomes of 49 patients with rectal adenocarcinoma and unresectable liver metastases who required palliative intervention between January 1989 and July 1996. Of these 49 patients, 24 underwent ETAR; the intraluminal tumor was resected using the urologic resectoscope to achieve a hemostatic, patent lumen. The outcomes of these patients were compared to those of the other 25 patients who had palliative LAR, APR, or a Hartmann procedure during the same period. The median distance of the tumors from the anal verge was similar (5 cm; range 1 to 15 cm). ETAR patients had a higher percentage of poorly differentiated tumors (35% vs. 6%, P = 0.034) and higher preoperative alkaline phosphatase values (478 +/- 75 mg/dl vs. 231 +/- 24 mg/dl; P < 0.015), suggesting more aggressive disease and greater hepatic tumor burden, respectively. Despite these differences, overall survival and time spent outside the hospital were similar in the two groups. The median number of debulking procedures required in the 24 ETAR patients was two (range 1 to 17). Resections in the 25 LAR/APR patients included LAR in 20, APR in two, and Hartmann procedures in three. There was a trend toward more stomas in the LAR/APR group (28% vs. 17%). More important, morbidity was significantly higher in the LAR/APR patients (24% vs. 4%; P = 0.049). In conclusion, ETAR is a safe alternative for the palliation of incurable rectal tumors. Compared to transabdominal resection, ETAR provides equivalent palliation as measured by survival and proportion of the patient's life spent outside the hospital, with a lower stoma rate and significantly less morbidity. Therefore, in select patients with metastatic rectal cancer, ETAR is an important palliative option.

Laparoscopically assisted colorectal surgery in the elderly

INTRODUCTION

Open colorectal surgery in elderly patients is associated with increased morbidity and mortality rates compared with those in younger age groups. It also requires more intensive postoperative support, longer hospitalization, and in many cases leads to prolonged rehabilitation or institutionalization. Because of its less invasive nature, laparoscopically assisted colorectal surgery may lead to a reduced period of convalescence. However, the safety of advanced laparoscopic surgical techniques in the elderly has not been established, so this prospective comparative study was undertaken.

METHODS

All patients aged 80 years or more who were undergoing an elective laparoscopic or open colorectal procedure between 1 January 1992 and 30 June 1997 were assessed prospectively. Patients having simple stoma formation were excluded. Perioperative care, operative results and subsequent function were analysed.

RESULTS

There were 42 patients in the laparoscopic group and 35 in the open group, with a median age of 84 years in each group. Five patients undergoing laparoscopic surgery required conversion to an open procedure. No complications related to laparoscopy occurred. Three patients died after operation in the laparoscopic group and four in the open group, with morbidity in seven and 15 patients respectively. Median hospital stay was 9 (range 4-21) days for patients having the laparoscopic operation, and 17 (range 7-28) days in the open cases. At 4 weeks after operation 30 of the 35 independent patients surviving the operation in the laparoscopic group and 16 of 28 in the open group were back to preoperative activity levels.

CONCLUSION

In this series laparoscopically assisted colorectal surgery was safe and was associated with a low incidence of complications, short hospitalization and a rapid return to preoperative activity levels when compared with open colorectal resections in this age group.

Evidence of improving survival of patients with rectal cancer in france: a population based study

BACKGROUND

Over the past 20 years there have been many changes in the management of rectal cancer. Their impact on the overall population is not well known.

AIMS

To determine trends in management and prognosis of rectal cancer in two French regions.

SUBJECTS

1978 patients with a rectal carcinoma diagnosed between 1978 and 1993.

METHODS

Time trends in treatment, stage at diagnosis, operative mortality, and survival were studied on a four year basis. A non-conditional logistic regression was performed to obtain an odds ratio for each period adjusted for the other variables. To estimate the independent effect of the period a multivariate relative survival analysis was performed.

RESULTS

Over the 16 year period resection rates increased from 66.0% to 80.1%; the increase was particularly noticeable for sphincter saving procedures (+30.6% per four years, p=0.03). The percentage of patients receiving adjuvant radiotherapy increased from 24.0% to 40.0% (p=0.02). The proportion of patients with Dukes' type A cancer increased from 17. 7% to 30.6% with a corresponding decrease in those with more advanced disease. Operative mortality decreased by 31.1% per four years (p=0.03). All these improvements have resulted in a dramatic increase in relative survival (from 35.4% for the 1978-1981 period to 57.0% for the 1985-1989 period).

CONCLUSIONS

Substantial advances in the management of rectal cancer have been achieved, but there is evidence that further improvements can be made in order to increase survival.

Curative surgery for colorectal cancer: long-term results and life expectancy in the elderly

PURPOSE

The long-term prognosis after curative surgery for colorectal cancer was evaluated in relation to age and life expectancy as a possible basis for assessing the risk to benefit ratios in the elderly.

METHODS

Data relating to 1,256 patients operated on from 1976 to 1994 were stored in a computer database prospectively from 1987. Patients were subdivided into four age groups (A = <60 years; B = 60-69; C = 70-79; D = > or =80). Distribution of general contraindications to curative surgery was examined. In the 869 patients who underwent curative treatment (A = 206; B = 256; C = 289; D = 118), distribution of tumor stage and elective/emergency surgery and the operative mortality rate were evaluated. Crude and age-corrected survival curves were calculated in 794 patients. The median crude survival of each group was related by gender and tumor stage to demographic life expectancy, assuming as "relative median survival index" the ratio between the two values.

RESULTS

General contraindications to curative surgery increased significantly with age. The operative mortality rate was higher in Group D than in Groups A, B, plus C over the total series (P < 0.001) and in both elective (P < 0.001) and emergency surgery (P < 0.05). Intergroup analysis of long-term survival rates showed significant differences between "crude" (P = 0.0057) but not age-corrected (P = 0.66) curves. The relative median survival index increased with age, up to approximately 1 in the local stages of Groups C and D.

CONCLUSIONS

To evaluate long-term results, elderly patients should be compared with unaffected, same-age subjects. Because the risks may be very high, the surgical policy in the elderly should be carefully weighed and related to life expectancy and actual results.

Fecal occult blood testing for colorectal cancer. Can we afford to do this?

Fecal blood is an inherently insensitive and nonspecific marker for asymptomatic colorectal neoplasia. As such, use of fecal occult blood tests (FOBTs) necessarily limits the effectiveness and efficiency of a screening application. FOBT screening may result in a modest reduction in colorectal cancer-specific mortality, but it alters neither colorectal cancer incidence nor overall mortality. Costs resulting from FOBT screening are substantial, and the extent to which screen-induced mortality offsets any benefits remains unknown. In the absence of a clearly demonstrated net benefit with FOBT screening, affordability of this expensive effort can be legitimately questioned.

Colon cancer in the elderly: evidence for major improvements in health care and survival

Time trends in therapeutic approaches and in the prognosis of colon cancer for patients aged 75 years and above have been investigated in comparison with corresponding trends for younger patients using a population-based series of 2089 colon cancer patients diagnosed between 1976 and 1990 in the Côte-d'Or area (478,000 inhabitants), Burgundy, France. Significant progress has been achieved in the management of patients with colon cancer in both age groups, but trends have been more noticeable in patients aged 75 years and above. In the elderly, the proportion of cancers limited to the digestive tract wall showed a 3-year average increase of 2.8% (P = 0.02) and the frequency of curative surgery an average increase of 8.6% (P < 0.001), so that it was performed in 80% of cases in the last 3-year period. Operative mortality decreased by 2.5% between 3-year periods (P < 0.004). Crude 5-year survival rates in elderly patients increased from 15% in the 1976-78 period to 29% in the 1985-87 period (P < 0.001), the corresponding figures being 36% and 44% (P > 0.10) in younger patients.

Endoscopic and surgical complications of work-up in screening for colorectal cancer

BACKGROUND AND PURPOSE

In an ongoing randomized screening study of 68,306 patients for early detection of colorectal neoplasm, those with positive Hemoccult II tests (Smith Kline Diagnostic, Sunnyvale, CA) were examined with a flexible sigmoidoscope (FS; 60 cm) and double-contrast barium enema (DCE). The aim of this study was to determine the rate of complications to the work-up.

METHODS

A total of 2,108 FS, 1,987 DCE, 190 colonoscopies, and 104 laparotomies were performed because of a positive Hemoccult.

RESULTS

One patient's large bowel was perforated during diagnostic endoscopy. Four perforations of the large bowel occurred during endoscopic polypectomy (0.8 percent of 513 adenomas removed), and one case of bleeding occurred 12 days after polypectomy. No complications occurred in connection with the 1,987 DCE. Five of 104 laparotomized patients underwent relaparotomy, 3 after removal of a colorectal carcinoma, and 2 of 4 patients with diverticular disease. All five patients healed but required a longer stay at the hospital.

CONCLUSIONS

Complications occurred in 0.3 percent of the endoscopies, and 5 percent of patients had to undergo laparotomy again. No mortality occurred. If mortality attributable to colorectal cancer will decrease because of screening, we find the complication rate is acceptable.

The influence of age on resection rates and postoperative mortality in 6457 patients with colorectal cancer

Due to the ageing of the general population, the proportion of elderly patients with colorectal cancer has increased. In a registry-based study, we evaluated the influence of age and other variables on resection rates and operative risk. Resection rates and postoperative mortality rates (30-day) were analysed in 6457 patients with colorectal cancer, diagnosed from 1985 through 1992 in hospitals connected to the Rotterdam Cancer Registry. Overall, 87% of the patients underwent resection but resection rates were lower for patients older than 89 years (67%) and for patients with rectal cancer (83%). The postoperative mortality rate was 1% for patients younger than 60 years and steadily increased with age. For patients 80 years and older the operative risk was 10%. According to multivariate analysis gender, age, subsite and stage were defined as independent prognostic factors. In view of the lack of alternatives, elderly patients with colorectal cancer should not be denied surgery on account of chronological age alone. Even in patients over 90 years of age resections can be performed with acceptable risk.

Local excision of rectal tumours

Local excision of colorectal tumour may be palliative or curative. Recent advances in minimal access techniques have allowed curative excision to be offered to a wider range of patients. Absolute indications for potentially curative local excision include mobile tumours, T1 tumours (assessed by ultrasonography), well or moderately differentiated histology (determined by biopsy) and tumour size less than 3 cm. Relative indications include T2 and T3 tumours (by ultrasonography), poorly differentiated histology (by biopsy) and tumour size greater than 3 cm depending on patient fitness. The rationale for these recommendations is described in detail.

Survival after peranal and abdominoperineal resection for rectal carcinoma

The outcome of a consecutive series of 47 patients with rectal cancer treated by endoscopic transanal resection or peranal local excision was contrasted with that of 42 patients undergoing abdominoperineal resection. Surgery was considered curative for 35 and nine patients treated by abdominoperineal and peranal resection respectively (P < 0.001). Patients undergoing peranal excision were older than those treated by abdominoperineal resection (median 77 versus 69 years, P < 0.01). The 5-year survival rate of patients undergoing peranal resection was 24 per cent compared with 33 per cent for those treated by the abdominoperineal procedure (P < 0.005). When surgery was palliative the survival rate after both procedures was the same. Survival after peranal excision was significantly poorer than that after abdominoperineal resection but this may be acceptable when the stage of disease and age of the patients are taken into account.

Emergency endoscopy: recanalization of intestinal obstruction caused by colorectal cancer

Endoscopic recanalization was attempted in 17 patients with obstruction caused by colorectal cancer who were at high surgical risk on account of their poor clinical condition. Combined use was made of pneumatic and mechanical dilation, debulking with a diathermal snare, and photoablation with neodymium-yttrium-aluminum-garnet laser. Successful recanalization was obtained in 94% of cases. The only failure was in a patient with a neoplasm of the rectosigmoid junction. Elective surgery was not performed on the patients after recanalization because of the presence of severe concomitant disease or diffuse metastasis. Patients were followed for 6.25 +/- 6.17 months with 1.6 +/- 0.7 treatments within the first month to stabilize patency and then with an average of 0.88 +/- 0.63 treatments per month to maintain patency. Only 2 patients had recurrence of obstruction, and the actuarial survival was 63% at 6 months and 23% at 1 year. Endoscopic treatment has proved effective because it allows rapid recanalization with resolution of emergency and maintenance of patency in patients for whom elective surgery is not indicated. In selected cases, therefore, endoscopic recanalization is a sound alternative to emergency surgery.

Long-term survival after endoscopic transanal resection of rectal tumours

The outcome and survival of 120 consecutive patients of median age 78 years with rectal tumours who underwent endoscopic transanal resection were assessed. Thirty-eight patients (32 per cent) were treated for large villous adenoma. These patients underwent a median of 2 (range 1-5) resections and the overall 5-year survival rate was 78.2 per cent. Of 82 patients with rectal cancer, 33 (28 per cent of the 120) had tumours amenable to conventional surgery but for the patient's age or infirmity. The 5-year survival rate of these patients was 29.7 per cent. Endoscopic transanal resection was used to palliate the symptoms of 49 patients (41 per cent) with rectal cancer; the 5-year survival rate was 13.7 per cent. Excellent long-term outcome may be achieved with endoscopic transanal resection for patients with benign rectal tumours. This approach also gives acceptable results for selected patients with rectal cancer in whom age, extent of disease or concurrent illness preclude conventional surgical resection.

Radiation enhancement of laser palliation for advanced rectal and rectosigmoid cancer: a pilot study

Laser palliation for advanced rectal or rectosigmoid cancer requires repeat treatments every four to six weeks. Thirteen patients (seven men, six women) age range 65-91 (median 81) received additional external beam radiotherapy in an attempt to reduce the frequency of laser treatments required. After successful laser recanalisation, patients were treated with a dose of 30-55 Gy in 10-20 fractions. Bowel symptoms were well controlled for prolonged periods in 11 patients (85%) and further laser procedures were only required every 19 weeks median (range 6-53 weeks). The laser energy required after radiotherapy was only 800 J/month (median). Survival was 14 months (median, range 2.5-20 months) for the seven patients who have died. Seven patients received laser treatment only for three months or more (median 14 weeks, range 13-39). In this group control of symptoms required procedures every four weeks (median) before radiotherapy and 20 weeks (median) afterwards. The laser energy required before radiotherapy was 15,000 J/month and 2000 J/month afterwards (Wilcoxon rank sum test, p < 0.01 for both). Radiotherapy was well tolerated in all but one patient. Three patients developed strictures after radiotherapy but all were dealt with endoscopically. There were no complications solely due to endoscopic procedures. Additional radiotherapy enhances laser palliation for inoperable rectal or rectosigmoid cancer.

Cancer in the elderly

This article reviews geriatric oncology and assesses options for treatment and care of the elderly patient with cancer. The size of the population over 65 years old is defined, with particular reference to the continuing growth of this subsection of the community. The high incidence of many cancers and their associated mortality rates in the elderly are identified and the epidemiology of such diseases in the geriatric population is addressed. Given the discrepancies in incidence and survival rates between patients younger and older than 65 years, the association between tumorigenesis and the aging process is explored. Specific aspects of tumor growth in the elderly are considered. General considerations of therapy for elderly patients with cancer are discussed, including the pharmacokinetics and pharmacodynamics of chemotherapy in those over 65 years old, surgical options, the use of radiotherapy, and overall patient assessment. Next, treatment options for individual cancer states are reviewed, with particular emphasis on newer treatment options designed specifically for the elderly. Sections on cancer screening and supportive care are also included, the latter dealing with aspects of symptom control, quality of life assessment, and the physical and psychologic rehabilitation of the elderly patient with cancer who is undergoing treatment. Conclusions are then drawn as to the extent of the oncological process in those over 65 years old, with particular emphasis on the underdiagnosis and undertreatment of many malignancies in the past. The challenge created by the growing elderly population is underscored and necessary plans of action for oncologists in the future are defined. Such proposals are necessary if inroads are to be made into the unacceptable morbidity and mortality rates borne by our elderly patients with cancer.

Staging and surgery for colorectal cancer

Staging of colorectal cancer has become increasingly important to select groups of patients for limited or more extensive surgery, and for adjuvant radiotherapy and chemotherapy. The main treatment is still surgery, but subgroups may benefit from adjuvant therapy, even accepting additional side effects. Accurate staging is necessary to define different treatment groups. A critical review is given of the present methods of clinicopathological staging.

Effect of subject age on costs of screening for colorectal cancer

STUDY OBJECTIVE

The aim was to estimate costs and yields of faecal occult blood screening and rescreening for colorectal cancer, for differing age cohorts.

DESIGN

Cost and clinical data were used as the basis for modelling the expected costs, and cost savings, resulting from the treatment of screen detected cancers, as compared with cancers detected by symptomatic presentation.

SETTING

Data were derived from the MRC screening trial currently in progress in Nottingham.

PARTICIPANTS

Approximately 140,000 subjects, age 50-79 years, were randomly allocated to a test (screened) and a control (unscreened) group.

MAIN RESULTS

The net costs of detecting and treating a cancer following colorectal screening fall as the age of the target population increases, owing principally to the increasing incidence of the disease with age. Generally, the marginal detection and treatment costs falls for all age groups with the first screening round, but rises considerably with the second. If allowance is made for cancers prevented as a result of early detection and excision of adenomas, the costs of screening are substantially reduced for all age groups.

CONCLUSIONS

Assuming a cost per QALY (quality adjusted life year gained) equivalent to that derived for the breast cancer screening programme, and a QALY gain from colorectal screening of one year, three screens, each separated by two years, appear economically justified for populations aged 60 years and above. Expected gains from cancer prevention make two screens justifiable for those between 45 and 59 years of age.

The transanal resectoscope: an under-used instrument?

The use of the urological resectoscope in the treatment of rectal tumours has been described in detail. We report the use of the purpose built transanal resectoscope in the treatment of 34 patients. Fourteen patients had villous adenomas and all but one were relieved of symptoms. Of 20 patients with rectal carcinoma, three presented with acute intestinal obstruction and three had rectal stump recurrences. Palliation was excellent in patients with general symptoms, but the results were disappointing for rectal stump recurrences. Transanal resection (TAR) is a novel form of treatment for patients with rectal obstruction. Two patients in this study had their obstruction successfully relieved by transanal resection alone. This allowed formal bowel preparation and full pre-operative assessment. We feel that this technique is under-used and that the results of treatment justify more widespread acceptance of the procedure.

Preoperative evaluation. Medical obstacles to surgery

The primary curative therapy for colorectal cancer is surgical resection. In addition, surgery is the mainstay for palliative therapy in most patients with more advanced colorectal cancer. Medical problems may have an impact on the decisions of when to operate and what procedure to do. Postoperative morbidity and mortality are affected by preoperative medical conditions. These medical problems may be secondary to the carcinoma, such as obstruction, perforation with sepsis, or malnutrition, or may be a result of underlying disorders, especially cardiopulmonary diseases. Adequate evaluation and indicated therapeutic intervention before surgical procedures will improve the patient's outcome.

Abdominal colon and rectal operations in the elderly

Sixty-seven abdominal operations for colon and rectal disorders were performed on 56 patients 80 years of age or older from January 1, 1984 to June 30, 1989. Nine patients required multiple operations. Sixty-two procedures (92 percent) were performed on patients in their ninth decade; two operations were performed on patients 95 years of age or older. Forty-five patients (80 percent) were operated upon for carcinoma. Operations included segmental colectomy (33 patients), low anterior resection (12 patients), total abdominal colectomy (3 patients) and abdominoperineal resection (2 patients). Forty patients were classified as ASA Class III; the majority were monitored in the surgical intensive care unit for a mean of 2.84 days. Thirty patients were monitored with arterial catheters and 21 with central invasive monitoring. Operative mortality was 7 percent (4 patients). Two patients died from diffuse carcinomatosis; one patient had a fatal myocardial infarction. The final death occurred from multisystem organ failure following anastomotic dehiscence. Twenty-seven operations were performed without postoperative complications; 18 operations were followed by a single minor complication. The average hospital stay was 18.96 days. All patients were admitted from home. Thirty-three returned home postoperatively; 16 were discharged to an extended care facility. In conclusion, elderly patients with colon and rectal disorders can be operated upon with acceptable morbidity and mortality. Age alone should not interdict surgical therapy.

Endoscopic transanal resection of rectal tumours--a preliminary report of its use

Endoscopic transanal resection (ETAR) of rectal tumours is a simple and inexpensive procedure, well tolerated in elderly patients or those undergoing palliation. We have performed 137 ETARs in 81 patients with a 30-day mortality rate of 11.1 per cent and a postoperative complication rate of 15.3 per cent. Thirty-one patients (38 per cent) had ETAR for palliation: in this group rectal bleeding was abolished or improved in 66 per cent of patients, altered bowel habit (diarrhoea) corrected in 77 per cent of patients, faecal incontinence improved in 50 per cent of patients and rectal pain (including tenesmus) improved in 50 per cent of patients. Twenty-three patients (28 per cent) were treated for large benign rectal polyps: in this group symptoms were universally abolished. The technique is particularly suited to the management of these patients. Twenty-seven elderly patients with theoretically 'curable' rectal cancer underwent ETAR with a 78 per cent crude survival rate at 1 year. While long-term results remain to be assessed, ETAR appears a useful technique for treating selected patients with rectal tumours.

Factors influencing mortality after curative resection for large bowel cancer in elderly patients

Mortality rates from the Large Bowel Cancer Project are presented with special reference to patients older than 70 years. The in-hospital mortality rate among those who underwent curative resection for colorectal carcinoma was 7%. Unlike long-term prognosis, which is influenced by pathological features, in-hospital mortality is influenced largely by clinical factors. Age was an adverse factor (78% of deaths occurred among those aged over 70, who formed 46% of the study population), as was obstruction or perforation. 55% of deaths were due to cardiopulmonary complications. Educating patients to seek treatment early, careful preoperative assessment and postoperative monitoring of cardiopulmonary function, and, in selected patients, use of local treatments rather than wide resections may help to reduce mortality in elderly patients.