Mortality and Survival after Surgical Treatment of Colorectal Cancer in Patients Aged over 80 Years

The impact of age on rectal cancer treatment, complications and survival

BACKGROUND

The number of older patients with rectal cancer is increasing. Treatment outcome discrepancies persist, despite similar treatment guidelines. To offer the oldest patients optimal individually adjusted care, further knowledge is needed regarding treatment strategy and outcome. The present study aimed to evaluate treatment, postoperative complications, and survival in older patients treated for rectal cancer.

METHODS

This retrospective study included all 666 patients (n=255 females, n=411 males) treated for rectal cancer at Levanger Hospital during 1980-2016 (n=193 <65 years, n=329 65-79 years, n=144 ≥80 years). We performed logistic regression to analyse associations between complications, 90-day mortality, and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

RESULTS

Despite a similar distribution of cancer stages across age-groups, patients aged ≥80 years were treated with a non-curative approach more frequently than younger age groups. Among patients aged ≥80 years, 42% underwent a non-curative treatment approach, compared to 25% of patients aged <65 years, and 25% of patients aged 65-79 years. The 90-day mortality was 15.3% among patients aged ≥80 years, compared to 5.7% among patients aged <65 years, and 9.4% among patients aged 65-79 years. Among 431 (65%) patients treated with a major resection with curative intent, the 90-day mortality was 5.9% among patients aged ≥80 years (n=68), compared to 0.8% among patients aged <65 years (n=126), and 3.8% among patients aged 65-79 years (n=237). The rate of postoperative complications was 47.6%. Pneumonia was the only complication that occurred more frequently in the older patient group. The severity of complications increased with three factors: age, American Society of Anaesthesiologists score, and >400 ml perioperative blood loss. Among patients that survived the first 90 days, the relative long-term survival rates, five-year local recurrence rates, and metastases rates were independent of age.

CONCLUSION

Patients aged ≥80 years were less likely to undergo a major resection with curative intent and experienced more severe complications after surgery than patients aged <80 years. When patients aged ≥80 years were treated with a major resection with curative intent, the long-term survival rate was comparable to that of younger patients.

Using period analysis to timely assess and predict 5-year relative survival for colorectal cancer patients in Taizhou, eastern China

INTRODUCTION

While timely assessment of long-term survival for patients with colorectal cancer (CRC) is essential for evaluation on early detection and screening programs of colorectal cancer, those data are extremely scarce in China. We aimed to timely and accurately assess long-term survival for CRC patients in eastern China.

METHODS

Patients diagnosed with CRC during 2004-2018 and followed up until December 31, 2018 from four cancer registries with high-quality data from Taizhou, eastern China were included. Period analysis was used to calculate 5-year relative survival (RS) for overall and the stratification by sex, age at diagnosis and region. The projected 5-year RS of CRC patients during 2019-2023 was also assessed using a model-based period analysis.

RESULTS

Overall 5-year RS for patients with CRC during 2014-2018 reached 78.8%, being 74.9% for men and 86.1% for women. 5-year RS declined along with aging, decreasing from 84.1% for age < 45 years to 48.9% for age > 74 years, while 5-year RS for urban area was higher compared to rural area (83.9% vs. 75.8%). Projected overall 5-year RS of CRC patients could reach 85.9% during the upcoming period 2019-2023.

CONCLUSIONS

We provided, for first time in China using period analysis, most up-to-date 5-year RS for patients with CRC from Taizhou, eastern China and also found 5-year RS for CRC patients have improved greatly during 2004-2018.

Post-Acquisition Hyperpolarized 29Silicon Magnetic Resonance Image Processing for Visualization of Colorectal Lesions Using a User-Friendly Graphical Interface

Medical imaging devices often use automated processing that creates and displays a self-normalized image. When improperly executed, normalization can misrepresent information or result in an inaccurate analysis. In the case of diagnostic imaging, a false positive in the absence of disease, or a negative finding when disease is present, can produce a detrimental experience for the patient and diminish their health prospects and prognosis. In many clinical settings, a medical technical specialist is trained to operate an imaging device without sufficient background information or understanding of the fundamental theory and processes involved in image creation and signal processing. Here, we describe a user-friendly image processing algorithm that mitigates user bias and allows for true signal to be distinguished from background. For proof-of-principle, we used antibody-targeted molecular imaging of colorectal cancer (CRC) in a mouse model, expressing human MUC1 at tumor sites. Lesion detection was performed using targeted magnetic resonance imaging (MRI) of hyperpolarized silicon particles. Resulting images containing high background and artifacts were then subjected to individualized image post-processing and comparative analysis. Post-acquisition image processing allowed for co-registration of the targeted silicon signal with the anatomical proton magnetic resonance (MR) image. This new methodology allows users to calibrate a set of images, acquired with MRI, and reliably locate CRC tumors in the lower gastrointestinal tract of living mice. The method is expected to be generally useful for distinguishing true signal from background for other cancer types, improving the reliability of diagnostic MRI.

Short and long-term outcomes of elderly patients undergoing left-sided colorectal resection with primary anastomosis for cancer

BACKGROUND

The proportion of elderly colorectal cancer (CRC) patients requiring surgery is increasing. Colorectal resection for left-sided cancers is the most controversial as the primary anastomosis or end-colostomy and open or minimally invasive approaches are available. Therefore, this study was conducted to investigate the short- and long-term outcomes in elderly patients after resection with primary anastomosis for left-sided CRC.

METHODS

The cohort study included left-sided colorectal cancer patients who underwent resection with primary anastomosis. The participants were divided into non-elderly (≤75 years) and elderly (> 75 years) groups. Short- and long-term postoperative outcomes were investigated.

RESULTS

In total 738 (82%) and 162 (18%) patients were allocated to non-elderly and elderly groups, respectively. Minimally invasive surgery (MIS) was less prevalent in the elderly (42.6% vs 52.7%, p = 0.024) and a higher proportion of these suffered severe or lethal complications (15.4% vs 9.8%, p = 0.040). MIS decreased the odds for postoperative complications (OR: 0.41; 95% CI: 0.19-0.89, p = 0.038). The rate of anastomotic leakage was similar (8.5% vs 11.7%, p = 0.201), although, in the case of leakage 21.1% of elderly patients died within 90-days after surgery. Overall- and disease-free survival was impaired in the elderly. MIS increased the odds for long-term survival.

CONCLUSIONS

Elderly patients suffer more severe complications after resection with primary anastomosis for left-sided CRC. The risk of anastomotic leakage in the elderly and non-elderly is similar, although, leakages in the elderly seem to be associated with a higher 90-day mortality rate. Minimally invasive surgery is associated with decreased morbidity in the elderly.

Risk scores to predict mortality 2 and 5 years after surgery for colorectal cancer in elderly patients

Background

The aim of this study was to identify predictors of mortality in elderly patients undergoing colorectal cancer surgery and to develop a risk score.

Methods

This was an observational prospective cohort study. Individuals over 80 years diagnosed with colorectal cancer and treated surgically were recruited in 18 hospitals in the Spanish National Health Service, between June 2010 and December 2012, and were followed up 1, 2, 3, and 5 years after surgery. Sociodemographic and clinical data were collected. The primary outcomes were mortality at 2 and between 2 and 5 years after the index admission.

Results

The predictors of mortality 2 years after surgery were haemoglobin ≤ 10 g/dl and colon locations (HR 1.02; CI 0.51–2.02), ASA class of IV (HR 3.55; CI 1.91–6.58), residual tumour classification of R2 (HR 7.82; CI 3.11–19.62), TNM stage of III (HR 2.14; CI 1.23–3.72) or IV (HR 3.21; CI 1.47–7), LODDS of more than − 0.53 (HR 3.08; CI 1.62–5.86)) and complications during admission (HR 1.73; CI 1.07–2.80). Between 2 and 5 years of follow-up, the predictors were no tests performed within the first year of follow-up (HR 2.58; CI 1.21–5.46), any complication due to the treatment within the 2 years of follow-up (HR 2.47; CI 1.27–4.81), being between 85 and 89 and not having radiotherapy within the second year of follow-up (HR 1.60; CI 1.01–2.55), no colostomy closure within the 2 years of follow-up (HR 4.93; CI 1.48–16.41), medical complications (HR 1.61; CI 1.06–2.44), tumour recurrence within the 2 years of follow-up period (HR 3.19; CI 1.96–5.18), and readmissions at 1 or 2 years of follow-up after surgery (HR 1.44; CI 0.86–2.41).

Conclusion

We have identified variables that, in our sample, predict mortality 2 and between 2 and 5 years after surgery for colorectal cancer older patients. We have also created risks scores, which could support the decision-making process.

Trial registration

ClinicalTrials.gov, NCT02488161.

Surgical and functional outcomes and survival following Colon Cancer surgery in the aged: a study protocol for a prospective, observational multicentre study

Background

The number of colorectal cancer patients increases with age. The decision to go through major surgery can be challenging for the aged patient and the surgeon because of the heterogeneity within the older population. Differences in preoperative physical and cognitive status can affect postoperative outcomes and functional recovery, and impact on patients’ quality of life.

Methods / design

A prospective, observational, multicentre study including nine hospitals to analyse the impact of colon cancer surgery on functional ability, short-term outcomes (complications and mortality), and their predictors in patients aged ≥80 years. The catchment area of the study hospitals is 3.88 million people, representing 70% of the population of Finland. The data will be gathered from patient baseline characteristics, surgical interventional data, and pre- and postoperative patient-questionnaires, to an electronic database (REDCap) especially dedicated to the study.

Discussion

This multicentre study provides information about colon cancer surgery’s operative and functional outcomes on older patients. A further aim is to find prognostic factors which could help to predict adverse outcomes of surgery.

Trial registration

ClinicalTrials.gov (NCT03904121). Registered on 1 April 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08454-8.

Risk factors of short-term survival in the aged in elective colon cancer surgery: a population-based study

PURPOSE

Patients aged > 80 years represent an increasing proportion of colon cancer diagnoses. Selecting patients for elective surgery is challenging because of possibly compromised health status and functional decline. The aim of this retrospective, population-based study was to identify risk factors and health measures that predict short-term mortality after elective colon cancer surgery in the aged.

METHODS

All patients > 80 years operated electively for stages I-III colon cancer from 2005 to 2016 in four Finnish hospitals were included. The prospectively collected data included comorbidities, functional status, postoperative surgical and medical outcomes as well as mortality data.

RESULTS

A total of 386 patients (mean 84.0 years, range 80-96, 56% female) were included. Male gender (46% vs 35%, p = 0.03), higher BMI (51% vs 37%, p = 0.02), diabetes mellitus (51% vs 37%, p = 0.02), coronary artery disease (52% vs 36%, p = 0.003) and rheumatic diseases (67% vs 39%, p = 0.03) were related to higher risk of complications. The severe complications were more common in patients with increased preoperative hospitalizations (31% vs 15%, p = 0.05) and who lived in nursing homes (30% vs 17%, p = 0.05). The 30-day and 1-year mortality rates were 6.0% and 15% for all the patients compared with 30% and 45% in patients with severe postoperative complications (p < 0.001). Severe postoperative complications were the only significant patient-related variable affecting 1-year mortality (OR 9.60, 95% CI 2.33-39.55, p = 0.002).

CONCLUSIONS

The ability to identify preoperatively patients at high risk of decreased survival and thus prevent severe postoperative complications could improve overall outcome of aged colon cancer patients.

Screening and systematic follow-up for cardiopulmonary comorbidity in elective surgery for colorectal cancer: a randomised feasibility study

BACKGROUND

One third of patients with colorectal cancer (CRC) have comorbidity, which impairs their postoperative outcomes. Scoring systems may predict mortality, but there is limited evidence of effective interventions in high-risk patients. Our aim was to test a trial setup to assess the effect of extra postoperative medical visits and follow-up on 1-year mortality and other outcomes in patients with cardiopulmonary risk factors undergoing elective surgery for colorectal tumours.

METHODS

Patients preoperatively screened positive for cardiopulmonary comorbidity were eligible. On postoperative day 4, they were randomised to either routine follow-up (RFU) or RFU with one extra medical visit and additional visits to the Cardiology and Respiratory Medicine Clinics 1 and 3 months postoperatively. The primary outcome measure was 1-year mortality; secondary outcome measures were length of stay (LOS), complications, and readmissions.

RESULTS

Of 673 screened patients 326 (48%) were found eligible, 108 declined participation, and 198 were randomised. Postoperative medical problems and/or need for intervention were found in 15-23% of the patients at the extra medical visits. The 90-day mortality was 0 and the 1-year mortality only 2.6% with no differences between the two groups. LOS and complication rates did not differ, but there were significantly fewer readmissions in the intervention group.

CONCLUSIONS

The 1-year mortality after elective CRC surgery was low, even in the presence of cardiopulmonary risk factors. There was no evidence of reduced mortality with additional medical follow-up in these patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02328365 registered 31 December 2014 (retrospectively registered).

Long-term results after elective laparoscopic surgery for colorectal cancer in octogenarians

BACKGROUND

The aim of this study was to investigate the short- and long-term outcomes after elective laparoscopic surgery (LPS) for colorectal cancer patients over 80 years of age.

METHODS

This was a retrospective study of all patients of 80 and above, who underwent elective colorectal resection, between January 2007 and January 2016. Data were analysed from a prospectively collected cancer database and cross checked with patient records. Determinants of survival were analysed using log-rank test and Kaplan-Meier curves.

RESULTS

We identified 293 patients; 110 underwent LPS. LPS had significantly better overall survival (p = 0.0065) and disease-free survival (DFS) (p = 0.006). The LPS group also had a shorter length of stay (LOS)-9 vs 11 days (p < 0.00001), 90-day mortality-5.5 vs 13.7% (p = 0.03) and required fewer blood transfusions 22.7 vs 40.4% (p = 0.002), when compared to open surgery (OPS). There was no difference in 30-day mortality 1.8 vs 4.9% (p = 0.22), anastomotic leakage 2.3 vs 6% (p = 0.20) or post-operative complication rates 44.5 vs 50.8% (p = 0.30).

CONCLUSIONS

LPS for patients in their 80s is characterised by better overall and DFS compared to open procedures and is associated with shorter post-operative LOS, and significantly lower 90-day mortality. Patients operated on laparoscopically also required fewer post-operative blood transfusions.

Current status of surgical treatment of colorectal liver metastases

Liver metastasis (LM) is one of the major causes of death in patients with colorectal cancer (CRC). Approximately 60% of CRC patients develop LM during the course of their illness. About 85% of these patients have unresectable disease at the time of presentation. Surgical resection is currently the only curative treatment for patients with colorectal LM (CRLM). In recent years, with the help of modern multimodality therapy including systemic chemotherapy, radiation therapy, and surgery, the outcomes of CRLM treatment have significantly improved. This article summarizes the current status of surgical treatment of CRLM including evaluation of resectability, treatment for resectable LM, conversion therapy and liver transplantation for unresectable cases, liver resection for recurrent CRLM and elderly patients, and surgery for concomitant hepatic and extra-hepatic metastatic disease (EHMD). We believe that with the help of modern multimodality therapy, an aggressive oncosurgical approach should be implemented as it has the possibility of achieving a cure, even when EHMD is present in patients with CRLM.