Disparities in the treatment of colon cancer in octogenarians

Presentation, Molecular Characteristics, Treatment, and Outcomes of Colorectal Cancer in Patients Older than 80 Years Old

Background: An increasing proportion of the population of patients with cancer presents at an advanced age, increasing the challenges of successful and well-tolerated treatments. In the older spectrum of the geriatric cancer patients, those older than 80 years old, challenges are even higher because of increasing comorbidities and decreasing organ function reserves. Methods: Studies regarding colorectal cancer presentation, treatment, and prognosis in patients older than 80 years old available in the literature were evaluated and were compiled within a narrative review. Molecular attributes of colorectal cancer in the subset of patients older than 80 years old in published genomic cohorts were also reviewed and were compared with similar attributes in younger patients. Results: Characteristics of colorectal cancer in octogenarians are in many aspects similar to younger patients, but patients older than 80 years old present more often with right colon cancers. Surgical treatment of colorectal cancer in selected patients over 80 years old is feasible and should be pursued. Adjuvant chemotherapy is under-utilized in this population. Although combination chemotherapy is in most cases not advisable, monotherapy with fluoropyrimidine derivatives is feasible and efficacious. Conclusions: Outcomes of colorectal cancer patients over the age of 80 years old may be optimized with a combination of standard treatments adjusted to the individual patient's functional status and organ reserves. Increased support for the older age group during their colorectal cancer treatment modalities would improve oncologic outcomes with decreasing adverse outcomes of therapies.

Factors affecting the post-operative outcomes in patients aged over 80 following colorectal cancer surgery

PURPOSE

In 2019, in Australia, there were 500,000 people aged 85 and over. Traditionally, clinicians have adopted the view that surgery is not desirable in this cohort due to increasing perioperative risk, perceived minimal clinical benefit, and shortened life expectancy. This cohort study is aimed at investigating postoperative outcomes from elective and non-elective colorectal cancer surgery in patients aged 80 and over.

METHODS

A retrospective analysis was conducted on patients from 2010 to 2020 on a prospectively maintained colorectal database. Patients aged over 80 who underwent surgical resection for colorectal cancer were reviewed. Oncological characteristics, short-term outcomes, overall survival, and relapse-free survival rates were analysed.

RESULTS

A total of 832 patients were identified from the database. Females comprised 55% of patients aged 80 and above. The median age was 84 for octogenarians and 92 for nonagenarians. Most patients were ASA 2 (212) or ASA 3 (501). ASA 3 and 4 and stage III pathology were associated with higher postoperative complications. Fifty percent of over 80 s and 37% of over 90 s were surgically discharged to their own home. Overall survival at 30, 180, and 360 days and 5 years was 98.1%, 93.1%, 87.2%, and 57.2% for the over 80 s and 98.1%, 88.9%, 74.9%, and 24.4% for the over 90 s.

CONCLUSION

Our results demonstrate that surgical treatment of older patients is safe with acceptable short-, medium-, and long-term survival. Nonetheless, efforts are needed to reduce the rates of complications in older patients, including utilisation of multi-disciplinary teams to assess the optimal treatment strategy and postoperative care.

Octogenarian patients with colon cancer - postoperative morbidity and mortality are the major challenges

Background

Few studies have addressed colon cancer surgery outcomes in an unselected cohort of octogenarian patients. The present study aimed to evaluate the relative survival of octogenarian patients after a major resection of colon cancer with a curative intent.

Methods

All patients diagnosed with colon cancer at Levanger Hospital between 1980 and 2016 were included. We performed logistic regression to test for associations between 90-day mortality and explanatory variables. We performed a relative survival analysis to identify factors associated with short- and long-term survival.

Results

Among 237 octogenarian patients treated with major resections with curative intent, the 90-day mortality was 9.3%. Among 215 patients that survived the first 90 days, the 5 year relative survival rate was 98.7%. The 90-day mortality of octogenarian patients was significantly higher than that of younger patients, but the long-term survival converged with that of younger patients. Among octogenarian patients, the incidence of colon cancer more than doubled during our 37-year observation period. The relative increase in patients undergoing surgery exceeded the increase in incidence; hence, more patients were selected for surgery over time. A high 90-day mortality was associated with older age, a high American Society of Anaesthesiologists (ASA) score, and emergency surgery. Moreover, worse long-term survival was associated with a high Charlson Comorbidity Index, a high ASA score, a worse TNM stage, emergency surgery and residual tumours. Both the 90-day and long-term survival rates improved over time.

Conclusion

Among octogenarian patients with colon cancer that underwent major resections with curative intent, the 90-day mortality was high, but after surviving 90 days, the relative long-term survival rate was comparable to that of younger patients. Further improvements in survival will primarily require measures to reduce the 90-day mortality risk.

Comparison between oxaliplatin therapy and capecitabine monotherapy for high-risk stage II-III elderly colon cancer patients

PURPOSE

45% of colon cancer patients are elderly, yet they are often deviated from standard cancer management. The MOSAIC trial favored FOLFOX over FL with superior oncologic outcomes; however, which regimen is most beneficial in elderly population remains unclear. This study aimed to compare the efficacy of oxaliplatin-added chemotherapy and capecitabine monotherapy in high-risk stage II/stage III elderly colon cancer patients.

METHODS

Colon cancer patients ≥70 years of age who received adjuvant chemotherapy at Inje University Busan Paik Hospital between February 2009 to April 2016 were included. Patients were separated into the oxaliplatin-added group and capecitabine monotherapy group. The primary outcomes were CSS and OS.

RESULTS

Of 74 patients, 45 received oxaliplatin-added chemotherapy and 29 received capecitabine monotherapy. There was no difference between the two groups in CSS or OS (p = 0.9670 and p = 0.6801, respectively). The N stage was significantly associated with CSS in both uni/multivariate analysis (p = 0.0565 and p = 0.0347, respectively). The oxaliplatin-added group had more stage III patients, so we performed a subgroup analysis of CSS and OS based on stage, which also showed no significant difference.

CONCLUSIONS

Capecitabine monotherapy is an oncologically safe regimen compared to oxaliplatin-added regimens in elderly patients with high-risk stage II/stage III colon cancer.

Should we resect colorectal cancer in patients over the age of 85?

BACKGROUND

The prevalence of colorectal cancer in the elderly is rising, with increasing numbers of older patients undergoing surgery. However, there is a paucity of information on the surgical outcomes and operative techniques used in this population.

AIM

To evaluate the post-operative outcomes for patients ≥ 85 years old following colorectal cancer resection as well as evaluating the outcomes of laparoscopic resection of colorectal cancer in patients over 85.

METHODS

Patients who underwent colorectal cancer resection at our institution between January 2010 and December 2018 were included. The study was divided into two parts. For part one, patients were divided into two groups based on age: Those age ≥ 85 years old (n = 48) and those aged 75-84 years old (n = 136). Short term surgical outcomes and clinicopathological features were compared using appropriate parametric and non-parametric testing. For part two, patient’s over 85 years old were divided into two groups based upon operative technique: Laparoscopic (n = 37) vs open (n = 11) colorectal resection. Short-term post-operative outcomes of each approach were assessed.

RESULTS

The median length of stay between patients over 85 and those aged 75-85 was eight days, with no statistically significant difference between the groups (P = 0.29). No significant difference was identified between the older and younger groups with regards to severity of complications (P = 0.93), American Society of Anaesthesiologists grading (P = 0.43) or 30-d mortality (2% vs 2%, P = 0.96). Patients over 85 who underwent laparoscopic colorectal resection were compared to those who underwent an open resection. The median length of stay between the groups was similar (8 vs 9 d respectively) with no significant difference in length of stay (P = 0.18). There was no significant difference in 30-d mortality rates (0% vs 9%, P = 0.063) or severity of complication grades (P = 0.46) between the laparoscopic and open surgical groups.

CONCLUSION

No significant short term surgical differences were identified in patients ≥ 85 years old when compared to those 75-85 years old. There is no difference in short term surgical outcomes between laparoscopic or open colorectal resections in patients over 85.

Analyzing non-cancer causes of death of colorectal carcinoma patients in the US population for the years 2000-2016

Background

Colorectal cancer (CRC) treatment and patient survival improved greatly. Consequently an increased incidence of non‐cancer‐related deaths is observed. This study analyzed the causes of non‐cancer death for people suffering from CRC based on the year of diagnosis, follow‐up time, and patient's age.

Methods

The data from patients diagnosed with CRC in the years 2000–2016 were taken from the Surveillance, Epidemiology, and End Results 18 database. Patients were categorized according to: death from CRC, non‐CRC cancer, and non‐cancer. Constituent ratios and standardized mortality ratios (SMRs) were calculated to describe the death causes distribution and relative death risks.

Results

Between 2000 and 2016, a stable and rapid drop for the original diagnosis as death cause for CRC patients was observed (70.19% to 49.35%). This was coupled to an increase in non‐cancer‐associated death reasons (23.38% to 40.00%). The most common non‐cancer death cause was heart disease, especially for elderly patients. However, deaths from accidents and adverse effects were frequent in younger CRC patients. Patients died from septicemia more often within the first follow‐up year; however, a 6‐fold increase in death from Alzheimer's disease was found for after at least 180 months follow‐up time.

The SMRs of all 25 non‐cancer death causes initially decreased in all CRC subgroups, followed by an increase with follow‐up times. Gradually decreasing SMR values were observed with increasing age of CRC patients.

Conclusions

These findings could help modify and sharpen preventive measures and clinical management and raise physician's awareness to potential non‐CRC death risk factors for CRC patients.

Clinical characteristics and treatment propensity in elderly patients aged over 80 years with colorectal cancer

BACKGROUND/AIMS

Elderly patients (≥ 80 years) with colorectal cancer (CRC) tend to avoid active treatment at the time of diagnosis despite of recent advances in treatment. The aim of this study was to determine treatment propensity of elderly patients aged ≥ 80 years with CRC in clinical practice and the impact of anticancer treatment on overall survival (OS).

METHODS

Medical charts of 152 elderly patients (aged ≥ 80 years) diagnosed with CRC between 1998 and 2012 were retrospectively reviewed. Patients' clinical characteristics, treatment modalities received, and clinical outcome were analyzed.

RESULTS

Their median age was 82 years (range, 80 to 98). Of 152 patients, 148 were assessable for the extent of the disease. Eighty-two of 98 patients with localized disease and 28 of 50 patients with metastatic disease had received surgery or chemotherapy or both. Surgery was performed in 79 of 98 patients with localized disease and 15 of 50 patients with metastatic disease. Chemotherapy was administered in only 24 of 50 patients with metastatic disease. Patients who received anticancer treatment according to disease extent showed significantly longer OS compared to untreated patients (localized disease, 76.2 months vs. 15.4 months, p = 0.000; metastatic disease, 9.9 months vs. 2.6 months, p = 0.001). Along with anticancer treatment, favorable performance status (PS) was associated with longer OS in multivariate analysis of clinical outcome.

CONCLUSION

Elderly patients aged ≥ 80 years with CRC tended to receive less treatment for metastatic disease. Nevertheless, anticancer treatment in patients with favorable PS was effective in prolonging OS regardless of disease extent.

Should Surgical Treatment Be Provided to Patients with Colorectal Cancer Who Are Aged 90 Years or Older?

PURPOSE

The number of patients aged ≥ 90 years is increasing worldwide; however, the treatment guidelines for colorectal cancer in elderly patients remain unclear. This study aimed to investigate the clinical outcomes of patients with primary colorectal cancer aged ≥ 90 years.

METHODS

We retrospectively reviewed the medical records of 100 patients (aged ≥ 90 years) with primary colorectal adenocarcinoma. Their demographic and clinical characteristics and surgical outcomes were assessed.

RESULTS

The patients who underwent tumor resections (n = 71) showed longer overall and cancer-specific survival than those who underwent non-operative treatments (n = 29) (median overall survival time: 23.92 months vs. 2.99 months, P < 0.0001). Age, body mass index, performance status, advanced cancer stage (stages 3 and 4), and treatment strategy were identified as risk factors, prognostic factors, and predictors of overall survival. No significant differences in the postoperative morbidity rate, in-hospital mortality rate, and survival time were found between the elective laparoscopic (n = 27) and elective open (n = 37) surgery subgroups. However, the in-hospital mortality rate was 6.25% (4/64) in the patients who underwent elective open surgeries and 42.9% (3/7) in those who underwent emergent open surgeries (p = 0.0179).

CONCLUSIONS

In clinical practice, surgical treatment should not be denied to patients with primary colorectal cancer aged ≥ 90 years. However, the high complication and mortality rates for emergency surgeries act as a deterrent. Further studies to eliminate the bias between operative and non-operative groups may be needed to validate our results.

Population-Based Patterns and Factors Associated With Underuse of Palliative Systemic Therapy in Elderly Patients With Metastatic Colon Cancer

BACKGROUND

We compared the patterns and factors associated with chemotherapy and bevacizumab use in elderly versus young patients with metastatic colon cancer (mCC) and determined the effect of systemic therapy on overall survival (OS) according to age.

MATERIALS AND METHODS

Patients diagnosed with mCC from 2009 to 2010 in British Columbia, Canada were reviewed and categorized as elderly patients (age ≥ 70 years) and young patients (age < 70 years). Cox regression models adjusted for age and confounders were used to determine the effect of systemic therapy on OS.

RESULTS

We identified 1013 patients with a median age of 67 years. Of the 1013 patients, 42% were elderly and 58% were young; 57% were men; and 66% had an Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0 or 1. Fewer elderly patients were offered systemic therapy compared with young patients (48% vs. 77%; P < .001). Among those treated, elderly patients were less likely than young patients to receive combination chemotherapy (47% vs. 81%; P < .0001) and bevacizumab (19% vs. 47%; P < .0001). The most common reasons for no treatment were similar for the elderly and young patients: patient choice, poor ECOG PS, and significant comorbidities. Advanced age alone was also cited as a reason for elderly but not for young patients (7% vs. 0%). When treated, the risk of adverse events and treatment interruptions was comparable between age groups. The receipt of systemic therapy was associated with improved OS in both elderly (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.37-0.56; P < .0001) and young (HR, 0.43; 95% CI, 0.35-0.53; P < .0001) patients, regardless of age (interaction P > .05).

CONCLUSION

In carefully selected elderly patients, the outcomes from systemic therapy were comparable to those for young patients. Thus, age alone should not be a barrier to treatment of mCC.

Colorectal Cancer Surgery in the Very Elderly: Nonagenarians

BACKGROUND

Surgery in the very elderly is a topic that has not been well studied, despite the steady rise in this population. With the rise in this population, there is now discussion on the safety of surgery in this cohort for colorectal cancer.

OBJECTIVE

The purpose of this study was to investigate elective and nonelective colorectal cancer surgery outcomes in patients aged ≥90 years at both private and public hospitals in Melbourne, Victoria, Australia.

DESIGN

This was a retrospective analysis of patients aged ≥90 years who were included in the prospectively maintained Cabrini Monash University Department of Surgery colorectal neoplasia database for patients entered between January 2010 and February 2015. Comorbidity, ASA score, acuity of surgery, treatment, mortality, morbidity, and survival were analyzed.

SETTINGS

This study was conducted in a tertiary referral hospital.

PATIENTS

A total of 48 patients were identified from the database. The majority of these patients were women (58.0%), ASA score III to IV (91.7%), and treated in an elective setting (79.2%). The median age was 91.8 years.

MAIN OUTCOME MEASURES

We measured 30-day mortality, 180-day mortality, and perioperative morbidity.

RESULTS

Thirty-day mortality rate was 2.1%. The 180-day mortality rate was 10.4%. A total of 29.2% of patients had a perioperative complication. Median follow-up was 21 months (range, 13-54 months). In 180-day mortality, minimally invasive surgery was associated with a lower mortality rate vs open surgery (p = 0.043). Perioperative complications were associated with nonelective surgery (p = 0.045), open surgery procedures (p = 0.014), and higher stages of disease (p = 0.014). A total of 81.3% of patients were able to return home after surgery.

LIMITATIONS

This was a retrospective study with the usual limitations; however, these have been minimized with the use of a high-quality, prospective data collection database. The median follow-up was 21 months.

CONCLUSIONS

Colorectal surgery was generally safe for nonagenarians in this study. This study demonstrates that excellent outcomes can be achieved in a selected group. Additional prospective studies with larger numbers and 5-year follow-up are recommended.

Patterns of Colorectal Cancer Care in the United States: 1990-2010

BACKGROUND

Colorectal cancer (CRC) mortality has declined in the United States, in part because of advances in treatment. Few studies have evaluated the adoption of therapies and temporal changes in patterns of care.

METHODS

Patients age 20 years and older diagnosed with stages II/III CRC were randomly sampled from the population-based Surveillance, Epidemiology, and End Results (SEER) program in 1990-1991, 1995, 2000, 2005, and 2010 (n = 7057). Therapy was obtained from medical records and physician verification. We described the receipt of chemotherapy and radiation therapy. Log-binomial regression was used to examine factors associated with therapy. All statistical tests were two-sided.

RESULTS

Chemotherapy receipt among colon cancer patients increased from 1990 (stage II: 22.5%; stage III: 56.3%) to 2005 (stage II: 32.1%; stage III: 72.4%) and declined slightly in 2010 (stage II: 29.3%; stage III: 66.4%). Stage III colon cancer patients who were older (vs <55 years, 75-79 years: risk ratio [RR] 0.81, 95% confidence interval [CI] = 0.71 to 0.91; ≥80 years: RR = 0.37, 95% CI = 0.28 to 0.47) or had a comorbidity score of 2 or higher (vs 0, RR = 0.56, 95% CI = 0.35 to 0.87) received chemotherapy less often. Receipt of radiation therapy by rectal cancer patients increased across all years from 45.5% to 66.1%. Increasing age (vs <55 years, 75-79 years: RR = 0.59, 95% CI = 0.47 to 0.74; ≥80 years: RR = 0.33, 95% CI = 0.25 to 0.45) was associated with lower chemoradiation use among stage II/III rectal cancer patients.

CONCLUSION

Our findings demonstrate increased adoption of chemotherapy and radiation therapy for colon and rectal cancer patients and differences in therapy by age, comorbidity, and diagnosis year. Increased receipt of these therapies in the community may further reduce CRC mortality.

Patterns of colorectal cancer care in the United States and Canada: a systematic review

Colorectal cancer is the third most common cancer in the United States and Canada. Given the high incidence and increased survival of colorectal cancer patients, prevalence is increasing over time in both countries. Using MEDLINE, we conducted a systematic review of the literature published between 2000 and 2010 to describe patterns of colorectal cancer care. Specifically we examined data sources used to obtain treatment information and compared patterns of cancer-directed initial care, post-diagnostic surveillance care, and end-of-life care among colorectal cancer patients diagnosed in the United States and Canada. Receipt of initial treatment for colorectal cancer was associated with the anatomical position of the tumor and extent of disease at diagnosis, in accordance with consensus-based guidelines. Overall, care trends were similar between the United States and Canada; however, we observed differences with respect to data sources used to measure treatment receipt. Differences were also present between study populations within country, further limiting direct comparisons. Findings from this review will allow researchers, clinicians, and policy makers to evaluate treatment receipt by patient, clinical, or system characteristics and identify emerging trends over time. Furthermore, comparisons between health-care systems in the United States and Canada can identify disparities in care, allow the evaluation of different models of care, and highlight issues regarding the utility of existing data sources to estimate national patterns of care.

Age-Related Treatment Disparities among Medicaid Beneficiaries with Metastatic Colorectal Cancer

Objective

To evaluate the impact of age on receipt of chemotherapy among low-income individuals with metastatic colorectal cancer.

Data Sources/Study Setting

North Carolina Medicaid enrollees with metastatic colorectal cancer diagnosed from 1999 to 2002 with colorectal as their only cancer (N=326).

Study Design

Retrospective analysis using linked data from the North Carolina Cancer Registry and Medicaid claims.

Data Collection/Extraction Methods

Outcomes were chemotherapy use within one year of diagnosis and time to initiation of chemotherapy. Cox regression models were fit to evaluate the association between chemotherapy use and age, stratifying for comorbidity, and adjusting for patient, community, and health services characteristics.

Principal Findings

Compared to 67.4% of patients aged <70 years, only 26.2% of patients ≥70 years received chemotherapy. After adjustment, younger patients with and without comorbidity were more likely to receive chemotherapy than older patients (hazard ratio (HR)=2.27, 95% confidence interval (CI) 1.41-3.66 and HR=6.33, 95% CI 2.87-13.96, respectively). Among those who received chemotherapy, the median time to receipt was 53 days, and did not differ significantly by age or comorbidity.

Conclusion

In this low-income cohort, older age was consistently associated with non-receipt of chemotherapy but not longer time to initiation of chemotherapy regardless of comorbidity status.

Utilization of bevacizumab in US elderly patients with colorectal cancer receiving chemotherapy

OBJECTIVE

Bevacizumab, the first FDA-approved anti-angiogenesis agent, has been used for metastatic colorectal cancer since 2004. This study evaluated the utilization of bevacizumab among elderly metastatic colorectal cancer patients in the United States.

METHODS

Using Surveillance and Epidemiology and End Results (SEER)-Medicare data, this retrospective cohort study consisted of individuals aged 65 years or older with a colorectal cancer diagnosis between 2005 and 2009, who received chemotherapy any time through 2010. This included patients with newly diagnosed metastatic colorectal cancer and patients who progressed from initially diagnosed earlier-stage disease. We ascertained comorbid conditions using ICD-9 codes and conducted logistic regression to identify patients' characteristics associated with bevacizumab use.

RESULTS

A total of 8645 patients were identified (mean age 74 years; 52% male); 57% of patients received bevacizumab with initially diagnosed metastatic colorectal cancer and 44% of patients with treated progressive or recurrent disease. After adjusting for other covariates, we found that patients aged ≥80 years were less likely to receive bevacizumab compared with those aged 65-69 years (odds ratio (OR), 0.64 (95% confidence interval (CI): 0.57-0.73)), or if they had evidence of comorbid cardiomyopathy/congestive heart failure (OR, 0.82 (CI: 0.70-0.95)) or arrhythmic disorder (OR, 0.85 (CI: 0.75-0.96)). Adoption of bevacizumab into practice was rapid following its approval, and the use increased from 36% to 40% from 2005 to 2010 (p = 0.013). There were significant regional variations in bevacizumab use.

CONCLUSIONS

Despite rapid uptake since its original approval, there appears to be low use of bevacizumab in elderly metastatic colorectal cancer patients in the United States. Regional variations and the strong effects of age and comorbidity suggest lack of consensus among oncologists regarding benefits and risks of bevacizumab in elderly patients.

Integrated oncogeriatric approach: a systematic review of the literature using concept analysis

OBJECTIVES

The purpose of this study was to provide a more precise definition of an integrated oncogeriatric approach (IOGA) through concept analysis.

DATA SOURCES

The literature was reviewed from January 2005 to April 2011 integrating three broad terms: geriatric oncology, multidisciplinarity and integrated care delivery models.

STUDY ELIGIBILITY CRITERIA

Citation selection was based on: (1) elderly cancer patients as the study population; (2) disease management and (3) case studies, intervention studies, assessments, evaluations and studies. Inclusion and exclusion criteria were refined in the course of the literature search.

INTERVENTIONS

Initiatives in geriatric oncology that relate to oncology services, social support services and primary care services for elderly cancer patients.

PARTICIPANTS

Elderly cancer patients aged 70 years old or more.

STUDY APPRAISAL AND SYNTHESIS METHODS

Rodgers' concept analysis method was used for this study. The analysis was carried out according to thematic analysis based on the elements of the Chronic Care Model.

RESULTS

The search identified 618 citations. After in-depth appraisal of 327 potential citations, 62 articles that met our inclusion criteria were included in the analysis. Three IOGA main attributes were identified, which constitute IOGA's core aspects: geriatric assessment (GA), comorbidity burden and treatment outcomes. The IOGA concept comprises two broad antecedents: coordinated healthcare delivery and primary supportive care services. Regarding the consequents of an integrated approach in geriatric oncology, the studies reviewed remain inconclusive.

CONCLUSIONS

Our study highlights the pioneering character of the multidimensional IOGA concept, for which the relationship between clinical and organisational attributes, on the one hand, and contextual antecedents, on the other, is not well understood. We have yet to ascertain IOGA's consequents. IMPLICATIONS OF KEY FINDINGS: There is clearly a need for a whole-system approach to change that will provide direction for multilevel (clinical, organisational, strategic) interventions to support interdisciplinary practice, education and research.

The impact of age on quality measure adherence in colon cancer

BACKGROUND

Recently lymph node yield (LNY) has been endorsed as a quality measure of colon cancer resection adequacy. It is unclear whether this measure is relevant to all ages. We hypothesized that total lymph node yield (LNY) is negatively correlated with increasing age and overall survival (OS).

STUDY DESIGN

The Surveillance, Epidemiology and End Results (SEER) database was queried for all nonmetastatic colon cancer patients diagnosed from 1992 to 2004 (n = 101,767), grouped by age (<40, 41 to 45, 46 to 50, and in 5-year increments until 86+ years). Proportions of patients meeting the 12 LNY minimum criterion were determined in each age group and analyzed with multivariate linear regression adjusting for demographics and American Joint Committee on Cancer (AJCC) 6(th) Edition stage. OS comparisons in each age category were based on the guideline of 12 LNY.

RESULTS

Mean LNY decreased with increasing age (18.7 vs 11.4 nodes/patient, youngest vs oldest group, p < 0.001). The proportion of patients meeting the 12 LNY criterion also declined with each incremental age group (61.9% vs 35.2% compliance, youngest vs oldest, p < 0.001). Multivariate regression demonstrated a negative effect of each additional year in age and log (LNY) with coefficient of -0.003 (95% CI -0.003 to -0.002). When stratified by age and nodal yield using the 12 LNY criterion, OS was lower for all age groups in stage II colon cancer with less than 12 LNY, and each age group over 60 years with less than 12 LNY for stage III colon cancer (p < 0.05).

CONCLUSIONS

Every attempt to adhere to proper oncologic principles should be made at the time of colon cancer resection regardless of age. The prognostic significance of the 12 LN minimum criterion should be applied even to elderly colon cancer patients.

Older patients and adjuvant therapy for colorectal cancer: surgeon knowledge, opinions, and practice

BACKGROUND

Increasing patient age independently predicts nonreferral and nonreceipt of adjuvant therapy among patients with colorectal cancer.

OBJECTIVE

This study aimed to identify factors affecting surgeons' decisions to refer older patients for adjuvant therapy.

DESIGN/SETTINGS/PARTICIPANTS

A self-administered survey was sent to all Australian and New Zealand colorectal surgeons (n = 146).

MAIN OUTCOME MEASURES

The survey consisted of 3 sections: 1) knowledge of research evidence, 2) opinions on evidence and adjuvant therapy in older patients, and 3) self-reported practice, or likelihood of patient referral in different scenarios. Demographic information was also obtained.

RESULTS

Seventy percent of surgeons responded. Surgeons were significantly less likely to refer older patients than younger patients for adjuvant therapy in all scenarios (P < .001). The difference in referral recommendations was greatest when patients lived a long way from treatment, had a comorbid condition, or had little social support. There was greater variation in referral recommendations for older patients, and marked disagreement between surgeons in knowledge and opinion questions. Surgeon age was the only significant predictor of survey responses. Greater knowledge and more positive opinions predicted similar referral recommendations for older and younger patients (P = .02, P = .01).

LIMITATIONS

Although decreased referral and receipt of adjuvant therapy among older patients is most likely multifactorial, this survey focused on the views of one physician group and a number of specific scenarios.

CONCLUSIONS

Chronological age alone appears to impact colorectal surgeons' decisions to refer patients for adjuvant therapy. Sociodemographic and physiological factors further decrease the likelihood of referral of older patients. A lack of consensus among surgeons suggests that more research is needed both to predict how older patients with cancer will react to treatment, and to determine how information from emerging evidence can be best used to assist physicians' treatment decisions.