Colorectal cancer in patients over 75 years of age—determinants of outcome

doi:10.1016/S0748-7983(97)80136-9

European Journal of Surgical Oncology (EJSO)

Volume 23, Issue 1, February 1997, Pages 13-19

https://doi.org/10.1016/S0748-7983(97)80136-9 Get rights and content

Two hundred and two consecutive patients with colorectal cancer, aged 75 years or older, diagnosed between 1980 and 1990, were followed up from the date of diagnosis until their death or until October 1994. Of these, 194 underwent some type of surgery, in 151 cases elective and in 43 emergency. The peri-operative mortality rate was 10.8% and the overall 5-year survival rate 28%. The ASA score was a predictor for both peri-operative mortality and survival. Peri-operative mortality was significantly increased among patients who had palliative operations, and those with post-operative complications and blood transfusions. Overall survival was worse for patients with absence of blood in the stools or absence of anaemia, for patients who lived in institutions pre-operatively, and for patients with advanced tumour stages. We conclude that the survival rate in elderly patients with colorectal cancer is acceptable after surgery. Old age is not a risk factor per se for peri-operative mortality or poor prognosis, and should not disqualify a person from operation.

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The influence of age on the outcome of treatment of elderly patients with colorectal cancer
2014, Journal of Geriatric Oncology
Citation Excerpt :
It was also the case that the elderly were more often females and had worse ASA scores. Studies have concluded that, after controlling for other risk factors, the early post-operative mortality in the elderly is not much different to that in the younger patients.4,20–30 However, in our study of older patients, as in some other recent larger studies,16,31–38 after adjusting for key risk factors, age itself was found to be an independent risk factor for 30-day and 6-month mortality.
We investigated factors associated with post-operative mortality rates in those aged ≥ 60, and in particular, the relative survival of age bands within this group.
Secondary analysis of a large comprehensive cohort of the elderly treated for colorectal cancer in the North of England during 1998–2003. We investigated seven risk factors associated with 30-day and 6-month post-operative mortality from colorectal surgery.
6083 patients aged ≥ 60 underwent colorectal cancer surgery. Approximately 8% had died within 30 days of surgery and 17% had died within 6 months. Thirty-day mortality was greater in the elderly (80 years +) compared to the young-old (60–69 years) (adjusted OR: 3.2, 95% CI 2.4 to 4.4). There was neither a significant difference between the proportions offered curative resections across the age-groups, nor was there a significant association between intent of surgery and 30-day mortality. Six-month mortality rose with age, but the association was stronger in those having curative surgery (adjusted OR: 3.8, 95% CI 2.8 to 5.2) than palliative surgery (adjusted OR: 1.5, 95% CI 1.1 to 2.1). Mortality from emergency surgery at 6-months was particularly high in elderly females.
This large population study adds more weight to the findings that age itself is a major risk factor in the outcome of colorectal surgery in elderly and that 30-day mortality underestimates the longer-term outcome in this age group. There was no significant association between radical resections and 30-day mortality in elderly patients compared to the younger age groups; however, a disproportionately higher mortality at 6 months was seen in elderly female patients.
Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis
2014, European Journal of Surgical Oncology
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This may lead to better use of maximum therapy leading to best oncological outcome in those deemed fit, and also increase the proportion of downstaged cancer suitable for local excision. This study was unable to adjust for differences in comorbidity associated with increasing age, including pre-operative frailty and peri-operative anaesthetic risk, both of which further influence survival.22 The impact of changing prevalence and severity of comorbidities at different ages has implications for targeted research into clinical and psychosocial interventions.23
With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients.
Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS).
With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70–79 years (stages I–III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70–79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001).
Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.
Surgical Management of Colon Cancer
2012, Colorectal Surgery
The survival gap between middle-aged and elderly colon cancer patients. Time trends in treatment and survival
2011, European Journal of Surgical Oncology
Citation Excerpt :
Although, in the present study we could not confirm the higher stage at diagnosis, but more elderly patients were registered with an unknown stage of disease which could include undiagnosed stage III and IV. Elderly patients are also less likely to receive adjuvant treatment and receive “suboptimal” management.22–27 Adjuvant chemotherapy has shown to be an effective treatment for elderly patients with stage III colon cancer, but the benefit is lower with older age.18,28,29
For several types of cancer, including colon cancer, the survival gap between middle-aged patients and elderly patients widened between 1988 and 1999 in Europe. The aim of our study was to describe treatments and compare survival rates over time (1991–2005) between middle-aged (<65 years), aged (65–74 years) and elderly (≥75 years) colon cancer patients in the mid-western part of the Netherlands to assess whether this survival gap further increased.
All 8926 patients with invasive colon cancer diagnosed between 1991 and 2005 were selected from the Comprehensive Cancer Centre West. Relative survival was calculated. Relative Excess Risks of death (RER) were estimated using a multivariable generalized linear model with a Poisson distribution.
There were no significant changes in the treatment for stage I and II colon. Patients with stage III and IV more often received chemotherapy over time (from 9.6% to 54.3% and from 7.5% to 44.2% for all ages, respectively), while less stage IV patients were operated on (from 73.1% to 55.2%). Relative 5-year survival increased significantly for middle-aged patients (RER = 0.97, 95%CI = 0.95–0.98, p < 0.001), borderline significantly (RER = 0.98, 95%CI = 0.97–0.99, p = 0.05) for elderly patients and not significantly for aged patients (RER = 0.99, 95%CI = 0.97–1.00, p = 0.08) after adjustment for sex, age, grade, stage, and treatment.
The survival gap earlier found by the EUROCARE is confirmed for the mid-western part of the Netherlands, even after adjustment for age, sex, grade, stage and treatment. However, present study does not show an increase in the survival gap between middle-aged and elderly patients.
The United Kingdom National Bowel Cancer Project - Epidemiology and surgical risk in the elderly
2007, European Journal of Cancer
Citation Excerpt :
In addition, in the event that elderly patients should require management in Intensive Care (ITU) postoperatively, it has been noted that their risk of additional complications such as anastomotic leakage is significantly higher.31 Radical surgery may not be the treatment of choice in this age group, with post-operative function and QoL, rather than cancer cure, being of relatively greater importance.32–35 If medical palliation, expectant management and colonic stenting for CRC are performed in favour of surgery, then this patient group will inevitably present as emergencies should their disease progress, and this may in part be reflected in the present results.
To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly.
Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest.
Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes’ stage was lower. They underwent surgery less often (81% versus 88%, p < 0.001), but more frequently needed urgent or emergency procedures (p < 0.001) and non-excisional surgery (7.7% versus 6.6%, p < 0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p < 0.001), and their median length-of-stay was 2 days longer (p < 0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes’ stage A and D disease, but not for other subgroups.
Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.
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2006, Cancer Treatment Reviews
Metastatic colorectal cancer remains a public-health issue on a global scale. With development of a new generation of cytotoxic agents, survival has improved for patients with metastatic disease. How to maximize the benefit of chemotherapy with acceptable toxicity remains uncompletely answered. Hepatic resection can provide a significant hope for long term survival, and a subset of patients might benefit from perioperative approaches. More recently, specific molecular processes have been targeted for therapeutic interventions, and encouraging results have been achieved using inhibitors of the Epidermal Growth Factor Receptor and the Vascular Endothelial Growth Factor.

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Original articleColorectal cancer in patients over 75 years of age—determinants of outcome

Lancet

Mortality statistics: England and Wales

The Cancer Registry

Colorectal cancer in patients over 70 years old

Isr J Med Sci

Elective versus emergency surgery for patients with colorectal cancer

Br J Surg

Decreased operative mortality from colorectal cancer but unchanged treatment results during 30–40 years

Läkartidningen

Curative resection: the major determinant of survival in patients with large bowel cancer

J Roy Coll Surg Edinb

Prospective study of colorectal cancer in the west of Scotland: 10-year follow-up

Br J Surg

Surgical treatment of colon and rectum adenocarcinoma in elderly patients

J Surg Oncol

Prognosis of elderly patients with large bowel cancer

Br J Surg

Surgery for colorectal cancer in the elderly patients

Acta Chir Scand

Surgery for carcinoma of the colon in people aged 75 years and older

Int J Colorect Dis

Risk factors and operative mortality in surgery for colorectal cancer

Ann Roy Coll Surg Eng

Original article
Colorectal cancer in patients over 75 years of age—determinants of outcome