Colorectal Cancer Surgery in the Elderly: Unimpressive Differences
ABSTRACT & COMMENTARY
Synopsis: Colorectal cancer is a disease of geriatric populations with the majority of cases appearing after the age of 70 years. This is a report of an exhaustive review of the medical literature with regard to operative morbidity and mortality, as well as survival after surgery with regard to patient age. When surgery is performed under emergency circumstances, older patients do not fare as well as younger patients. However, under elective conditions, operative morbidity and mortality as well as survival are comparable.
Source: Colorectal Cancer Collaborative Group. Lancet 2000;356:968-974.
Colorectal cancer is largely a disease of older people. More than 70% of the cases occur in those older than 65 years of age, and we are bracing ourselves for its increased prevalence with the aging of the population. For most patients the primary and most important therapeutic approach is initial surgery; and survival is tightly linked to the ability to resect with curative intention. However, clinicians are frequently challenged with decisions about surgical approaches, particularly in frail elderly patients with limited life expectancy. The purpose of the report from the Colorectal Cancer Collaborative Group in the United Kingdom was to examine the outcomes of surgery in elderly patients in comparison to younger age groups.
Systematic and careful reviews of published reports identified by computerized and manual searches of the medical literature and direct solicitation from investigators was undertaken. Within each study, outcomes for patients with regard to operative morbidity and mortality as well as survival were analyzed for patients aged 65-74 (young-old), 75-84 (older-old), and 85+ (oldest-old), and compared to those younger than 65 years of age.
From 28 independent studies and a total of 34,194 patients, the following observations were gleaned. Older patients had more comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery and less likely to have curative-intention surgery than younger patients. For the whole group, the incidence of postoperative morbidity and mortality increased progressively with advancing age and overall survival was reduced in the older groups. However, the differences in operative mortality and survival were not striking. Furthermore, when examining the cases that involved elective surgery (i.e., eliminating the data from those patients requiring emergency surgery), the differences in untoward operative consequences and overall survival were much less apparent, reaching significance only for the oldest-old.
COMMENT by William B. Ershler, MD
This is a credible report of a thorough analysis of much, if not all, of the data currently available regarding colorectal cancer surgery in the elderly. The data from each study was analyzed separately by a complex and exhaustive study protocol that involved several researchers. A meta-analysis of these reports might have provided a more precise assessment of the absolute or relative survival in each age group but the Colorectal Cancer Collaborative Group rightfully contend that such an analysis would have been less useful because of the inherent differences in the reports with regard to case mix and interventions. In fact, the methods of data presentation in this report provide an excellent model for outcome assessment from heterogeneous published reports in the context of determining age-related differences.
The findings were modest and expected. Older people have more advanced disease at presentation. This is not a new observation and although not completely understood, may be related to access to health care and reluctance to undergo evaluation. Certainly, later stage at presentation is also observed for older patients with other common tumors, such as breast cancer.
Older people were also found to have more operative complications such as anastamotic leak, thromboembolism, respiratory and cardiac complications, and stroke. However, if one excludes emergency surgery, the complication rates were comparable to younger patients. This is also true for data regarding survival. There is no question that overall survival is less for the older groups. However, more patients in the later age groups present as emergency cases and surgery in these cases is generally palliative. When the data was examined for elective surgery with curative intention, operative morbidity and mortality and two and five-year survival rates are comparable among the age groups, including those younger than 65 years of age.
Colorectal cancer is the most prevalent lethal malignancy in geriatric populations. The data are clear that effective surgery can provide years of added life if diagnosis is made in a timely fashion and surgical resections are elective. Screening and prompt diagnostic interventions are of paramount importance in this regard.
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