Are we undertreating rectal cancer in the elderly? An epidemiologic study

Age-related differences in progression patterns, follow-up strategies, and postoperative outcomes in locally advanced rectal cancer: insights from a large-scale validated study

Background

Locally advanced rectal cancer (LARC) presents significant treatment challenges, particularly as patient age may influence disease progression and treatment response. Understanding the differences in progression patterns and treatment outcomes between older patient (OP) and non-older patient (NOP) is essential for tailoring effective management strategies.

Objectives

We aimed to explore the differences of progression pattern, postoperative treatment, and survival outcome between OP and NOP groups in LARC.

Design/Methods

The random survival forest model was used to determine the probability of time-to-event occurrence every 3 months. Patients in the NOP and OP group were both categorized into three risk groups based on progression-free survival nomogram scores. We employed inverse probability of treatment weighting (IPTW) analysis and the Surveillance, Epidemiology, and End Results (SEER) database to verify our findings.

Results

Our results revealed that Groups 1, 2, and 3 experienced peaks in progression within the first 24 months in NOP group. As for OP group, Group 4 reached a progression peak at the 18th month, Group 5 at the 12th month, and Group 6 at the 9th month. In NOP group, high-risk patients who underwent postoperative chemotherapy had significantly improved overall survival compared to those who did not. Additionally, postoperative chemotherapy did not significantly improve prognosis for patients in low-, moderate-, or high-risk groups of OP group. Finally, the validation results of IPTW analysis and SEER database showed compliance with our findings.

Conclusion

For NOP group, we recommended close follow-up during the first 2 years. As for OP group, it was suggested to conduct close follow-up at the 18th, 12th, and 9th month for low-, moderate-, and high-risk groups, respectively. Furthermore, postoperative chemotherapy can provide survival benefits for patients in high-risk group of NOP group. However, OP group patients should be informed that the potential benefits of postoperative chemotherapy may be minimal.

Perioperative Glutamine Supplementation May Restore Atrophy of Psoas Muscles in Gastric Adenocarcinoma Patients Undergoing Gastrectomy

BACKGROUND

Sarcopenia, characterized by degenerative skeletal muscle loss, is increasingly linked to poor surgical outcomes. Glutamine, an immune-modulating formula, may stimulate muscle protein synthesis and inhibit degradation. We used the psoas major muscle area (PMMA) at the third lumbar vertebra, normalized for height (PMMA index), as a skeletal muscle indicator. This study investigates whether perioperative glutamine supplementation mitigates psoas muscle atrophy.

METHODS

We enrolled gastric adenocarcinoma (GA) patients undergoing gastrectomy. Computed tomography assessed the psoas muscle short axis. Muscle atrophy was estimated by changes between preoperative and three-month post-gastrectomy scans. Perioperative glutamine supplementation (PGS) comprised five-day parenteral plus one-month oral use. Propensity score matching minimized potential bias. A linear regression model predicted the association.

RESULTS

Of 516 patients analyzed (2016-2019), 100 (19.4%) received PGS. After propensity score matching, each group contained 97 cases. The PGS group showed a significantly higher median PMMA index change than the non-PGS group (0.3 vs. -0.3 cm2/m2, p = 0.004). Multivariate analysis revealed that PGS was significantly associated with increased PMMA index (coefficient = 0.60; 95% CI: 0.19-1.01; p = 0.005).

CONCLUSIONS

PGS may help restore psoas muscle atrophy in GA patients undergoing gastrectomy. The underlying mechanisms likely relate to glutamine's role in protein metabolism and immune function. Further studies are needed to elucidate these mechanisms fully.

Evaluation of treatment outcomes and tolerability in older patients with rectal cancer treated with radiotherapy accompanied by the G-8 geriatric score: TROD13-003 multicenter study

INTRODUCTION

The choice of treatment for rectal cancer often differs in older and younger patients, with the rate of radiotherapy use lower among older adults. In our daily practice, when evaluating a frail older patient with rectal cancer, we usually choose to give less treatment. This may be due to concern that the patient will not be able to tolerate radiotherapy. The Geriatric 8 score (G8GS) is a guide to evaluating treatment tolerability as it relates to frailty in older adults with cancer. The aim of this study was to evaluate treatment outcomes and tolerability in older patients with rectal cancer treated with radiotherapy (RT) accompanied by G8GS.

MATERIALS AND METHODS

Patients aged 65 and older with stage I-III rectal adenocarcinoma who were treated with RT and had a G8 evaluation were included in this multicenter retrospective study. Prognostic factors related to G8GS were calculated using Chi-square and logistic regression tests and survival rates were calculated by the Kaplan-Meier test using the SPSS v24.0 software. All p-values ≤0.05 were considered statistically significant.

RESULTS

A total of 699 patients from 16 national institutions were evaluated. The median age was 72 years (range 65-96), and the median follow-up was 43 (range 1-190) months. Four hundred and fifty patients (64%) were categorized as frail with G8GS ≤14 points. Frail patients had higher ages (p = 0.001) and more comorbidities (p = 0.001). Ability to receive concomitant and/or adjuvant chemotherapy rates were significantly higher in fit patients (p = 0.002 and p = 0.001, respectively). No significant difference was observed in terms of grade 3-4 early and late toxicity for both groups. Cancer-related death was higher (p = 0.003), and 5- and 8-year survival rates were significantly lower (p = 0.001), in the frail group. Age and being frail were significantly associated with survival.

DISCUSSION

Radiotherapy is a tolerable and effective treatment option for older adults with rectal cancer even with low G8GS. Being in the frail group according to G8GS and having multiple comorbidities was negatively associated with survival. Addressing the medical needs of frail patients through a comprehensive geriatric assessment prior to radiotherapy may improve G8GS, allowing for standard treatment and increased survival rates.

Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis

BACKGROUND

The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes.

METHODS

Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type.

RESULTS

A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts.

CONCLUSION

Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.

Postoperative decline in renal function after rectal resection and all-cause mortality: a retrospective cohort study

AIM

Fluid loss, dehydration and resultant kidney injury are common when a diverting ileostomy is formed during rectal cancer surgery, the consequences of which are unknown. The aim of this retrospective single-site cohort study is to evaluate the impact of sustained postoperative renal dysfunction after rectal resection on long-term renal impairment and survival.

METHOD

All patients with rectal adenocarcinoma undergoing resection between January 2003 and March 2017 were included, with follow-up to June 2020. The primary outcome was impact on long-term mortality attributed to a 25% or greater drop in estimated glomerular filtration rate (eGFR) following rectal resection. Secondary outcomes were the long-term effect on renal function resulting from the same drop in eGFR and the effect on long-term mortality and renal function of a 50% drop in eGFR. We also calculated the effect on mortality of a 1% drop in eGFR.

RESULTS

A total of 1159 patients were identified. Postoperative reductions in eGFR of 25% and 50% were associated with long-term overall mortality with adjusted hazard ratios of 1.84 (1.22-2.77) (p = 0.004) and 2.88 (1.45-5.71) (p = 0.002). The median survival of these groups was 86.0 (64.0-108.0) months and 53.3 (7.8-98.8) months compared with 144.5 (128.1-160.9) months for controls. Long-term effects on renal function were demonstrated, with those who sustained a >25% drop in renal function having a 38.8% mean decline in eGFR at 10 years compared with 10.2% in controls.

CONCLUSION

Persistent postoperative declines in renal function may be linked to long-term mortality. Further research is needed to assess causal relationships and prevention.

Association of age with outcomes in locally advanced rectal cancer treated with neoadjuvant therapy followed by surgery

INTRODUCTION

We aimed to assess the association of age with outcomes in patients with Locally Advanced Rectal Cancer (LARC) who received neoadjuvant therapy followed by major surgery.

METHODS

Retrospective review of 328 patients with LARC, N = 99 < 70 years (younger) versus N = 229 ≥ 70 years (elderly) from 2004 to 2018.

RESULTS

Elderly patients had a higher American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI), length of stay and 30-day readmissions (p < 0.05). They also had worse overall survival (OS) & disease-free survival (DFS) (p < 0.001), but similar disease-specific survival (DSS) compared to younger group. Age was not associated with hazard of death (HR 1.01, 0.98-1.03). Rather, CCI (HR 1.29, 1.01-1.5), extramural vascular invasion (HR 4.98, 2.84-8.74), and adjuvant therapy (0.37, 0.21-0.64) were significantly associated with the hazard of death; when controlled for stage, tumor distance from anal verge, and neoadjuvant completion.

CONCLUSION

Comorbidities and lower rates of adjuvant therapy, and not chronologic age, are associated with poor OS of elderly patients with LARC treated with neoadjuvant therapy and major surgery.

Geriatric Radiation Oncology: What We Know and What Can We Do Better?

Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.

Guidance for Treating the Older Adults with Colorectal Cancer

OPINION STATEMENT

The need for evidence-based data in the rapidly growing group of older patients is vast and more elderly-specific studies are desperately needed, for which there is clear demand from both patients and providers. Notably, many of the studies discussed in this review included unplanned subset analyses based on age and/or were not originally stratified by age; therefore, these data, particularly overall survival data, need to be interpreted with some caution as they may not be statistically valid based on the initial trial design and statistical plan. As we await data from ongoing elderly-specific trials, our recommendation for managing older patients with CRC should include geriatric screening tools (e.g., CSGA, VES-13, G8, CARG, CRASH) to help guide treatment adjustments for improved tolerability without sacrificing efficacy. For patients with a positive screen for significant geriatric concerns, a full geriatric assessment is recommended to guide treatment approach and supportive care. Prior data support the use of all approved medications for CRC in older adults who are fit; however, treatment breaks and dose attenuation with potential escalation are reasonable options for these patients. Ultimately, management decisions in the care of older adults with mCRC must be made through shared decision-making with the patient with consideration for the patient's functional status, comorbidities, goals of care, social support, as well as potential toxicities and possible effect on QoL.

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

Background

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences.

Methods

A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model.

Results

The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80–84 years, 4% in the 85–90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0–I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age.

Conclusions

Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.

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.

Emergency Surgery for Colon Diseases in Elderly Patients-Analysis of Complications, and Postoperative Course

Background and Objectives: Colon diseases can turn in a clinical emergency with the onset of some important complications. Some critical conditions are more common in aged patients because they are frailer. The aim of this study is to examine patients over 80 years of age who are undergoing emergency colorectal surgery, and evaluating the aspects associated with post-operative complications and other problems in the short term. Methods: From November 2020 to February 2022, we included 32 consecutive patients older than 80 undergoing emergency surgery due to colon diseases. We collected and analysed all demographic and operative data, and then applied CR-POSSUM score and correlated this with postoperative hospital stay and the onset of postoperative complications according to the Clavien Dindo classification. Results: Postoperative factors were selectively evaluated based on the clinical scenario and different colic pathologies. There were no statistically significant differences, in terms of postoperative hospital stay, postoperative complications, reoperation rate and 30-day mortality. The number of cases of blood transfusions was significant and was more numerous in cases of intestinal perforation and bleeding cases. The value of the Operative Severity Score in bowel perforations was significantly higher. Conclusions: The use of a score to stratify the risk is a useful tool, especially in elderly patients undergoing emergency surgery. The CR-POSSUM score was important for predicting morbidity in our study. Emergency manifestations of colon diseases in the elderly show higher morbidity and mortality rates. The effect of age on outcome is a concept that needs to be emphasized, so further investigation is needed.

An assessment of left-digit bias in the treatment of older patients with potentially curable rectal cancer

BACKGROUND

Patient age is associated with poorer rectal cancer treatment compliance. However, it is unknown whether left-digit bias (disproportionate influence of leftmost age digit) influences this association.

METHODS

The patients diagnosed with stage I-III rectal cancer between 2006 to 2017 in the National Cancer Database were identified. The association between age and receipt of guideline-adherent care was assessed using mixed-effects multivariable analyses.

RESULTS

Among 97,960 patients, 46.2% received guideline-adherent overall treatment and 73.3% underwent guideline-adherent surgical resection. Of those who underwent guideline-adherent surgery, 86.4% received guideline-adherent radiotherapy and 56.6% received guideline-adherent chemotherapy. After risk-adjustment, each decade increase in age was associated with 36% decreased odds of guideline-adherent therapy (odds ratio = 0.64, 95% confidence interval = 0.63-0.65). Patients aged 58 to 59 (odds ratio = 1.15, 95% confidence interval = 1.02-1.27) and 78 to 79 (odds ratio = 1.28, 95% confidence interval = 1.08-1.51) had higher odds of guideline-adherent overall treatment compared with patients aged 60 and 80, respectively. However, there were no significant differences in the receipt of guideline-adherent treatment between patients aged 60 vs 61-62 and 80 vs 81-82.

CONCLUSION

Older patients with rectal cancer are less likely to receive guideline-adherent care, and a left-digit bias is present. Geriatric assessment-guided treatment decisions could help mitigate this bias.

Economic burden of patients living with heart disease in the last years of life in Australia: a retrospective analysis using linked data

AIMS

People living with heart disease are at elevated risk of hospitalization during the last years of their life. The aim of this study was to describe hospitalization-related usage patterns, and associated cost burden, for patients living with heart disease in the last 6 years of their life.

METHODS AND RESULTS

The study was an observational cohort study, using routinely collected and linked data from hospital admission (HA), emergency department (ED) presentation and death registry data in Queensland, Australia. The study sample included 1000 randomly selected patients who died in 2017 due to any cause who had been living with heart disease for at least the prior 6 years. The two main outcomes of interest in this study were cost of HAs and cost of ED presentation in the last 6 years before death. Total cost was calculated as a sum of direct and overhead costs from each of the hospital presentations. The mean HA per patient in the sixth year, second year, and last year prior to death was 5.3, 6.6, and 7.5, respectively, with a similar pattern observed for ED presentations. The associated costs per patient from HA followed a similar trajectory increasing gradually from $17 711 in the sixth year to $26 658 in the second last year prior to death. A similar pattern was observed for ED presentation costs.

CONCLUSION

The large increase cost in the last year of life was primarily attributable to higher treatment cost per HA at end of life.

Efficacy and safety of sequential neoadjuvant chemotherapy and short-course radiation therapy followed by delayed surgery in locally advanced rectal cancer: a single-arm phase II clinical trial with subgroup analysis between the older and young patients

Purpose

This study was performed to investigate the efficacy and safety of short-course radiation therapy (SCRT) and sequential chemotherapy followed by delayed surgery in locally advancer rectal cancer with subgroup analysis between the older and young patients.

Materials and Methods

In this single-arm phase II clinical trial, eligible patients with locally advanced rectal cancer (T3–4 and/or N1–2) were enrolled. All the patients received a median three sequential cycles of neoadjuvant CAPEOX (capecitabine + oxaliplatin) chemotherapy. A total dose of 25 Gy in five fractions during 1 week was prescribed to the gross tumor and regional lymph nodes. Surgery was performed about 8 weeks following radiotherapy. Pathologic complete response rate (pCR) and grade 3–4 toxicity were compared between older patients (≥65 years) and younger patients (<65 years).

Results

Ninety-six patients with locally advanced rectal cancer were enrolled. There were 32 older patients and 64 younger patients. Overall pCR was 20.8% for all the patients. Older patients achieved similar pCR rate (18.7% vs. 21.8; p = 0.795) compared to younger patients. There was no statistically significance in terms of the tumor and the node downstaging or treatment-related toxicity between older patients and younger ones; however, the rate of sphincter-saving surgery was significantly more frequent in younger patients (73% vs. 53%; p=0.047) compared to older ones. All treatment-related toxicities were manageable and tolerable among older patients.

Conclusion

Neoadjuvant SCRT and sequential chemotherapy followed by delayed surgery was safe and effective in older patients compared to young patients with locally advanced rectal cancer.

Rectal cancer treatment and outcomes in elderly patients treated with curative intent

The elderly population comprises a significant proportion of patients diagnosed with rectal cancer. However, there is a lack of evidence to guide treatment decisions in this group. Thus, this multicentre study compares the histopathology, treatment patterns and outcomes between the elderly and young populations with non-metastatic rectal cancer. The present study reported on the clinicopathological variables, treatment modalities and survival outcomes in 736 patients diagnosed with non-metastatic rectal cancer between 2006 and 2015. Patients were divided into the following two groups, <70 and ≥70 years of age, which were compared using Chi-square and survival outcome analysis using Kaplan-Meier. Elderly patients made up nearly half of the cohort and were less likely to undergo trimodality therapy or be discussed in a multidisciplinary meeting. Surgery in the elderly patients was associated with increased mortality. Elderly patients had worse cancer-specific survival (75 vs. 85%), which was particularly evident in stage III disease (hazard ratio, 2.1). Elderly patients in this subgroup treated with trimodality therapy had similar survival outcomes to younger patients. Elderly patients with locally advanced rectal cancer comprise a large proportion of the patient cohort. Consideration should be given for trimodality therapy in this group, taking into account biological age, especially in the context of increasing life expectancy and improvement in the management of age-related comorbidities.

Neoadjuvant Therapy in Stage II/III Rectal Cancer: A Retrospective Study in a Disparate Population and the Effect on Survival

BACKGROUND

Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown.

OBJECTIVE

This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival.

DESIGN

This is a retrospective database review.

SETTINGS

This study was conducted by utilizing the Kentucky Cancer Registry at an academic center.

PATIENTS

All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival.

RESULTS

Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens.

LIMITATIONS

This study was limited by the retrospective nature of the review and by unmeasured confounders.

CONCLUSIONS

Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596.

TERAPIA NEOADYUVANTE EN EL MANEJO DEL CNCER DE RECTO EN ESTADIO II / III UN ESTUDIO RETROSPECTIVO EN UNA POBLACIN DISPAR Y EL EFECTO EN LA SUPERVIVENCIA

ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cáncer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la población que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atención de alto nivel es muy bajo. El tratamiento del cáncer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cáncer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISEÑO:Revisión retrospectiva de una base de datos.ESCENARIO:Este estudio se llevó a cabo utilizando el Registro de Cáncer de Kentucky en un centro académico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibió terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no académicos. El análisis de la supervivencia mostró una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparación con otros esquemas de tratamiento.LIMITACIONES:Revisión retrospectiva, factores de confusión no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cáncer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta población, por lo tanto se deben hacer esfuerzos en las políticas de salud, así como en educación, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no académicos. El centralizar la atención del cáncer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales económicamente, con acceso deficiente a la posibilidad de recibir atención de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

Clinical and oncologic outcomes of laparoscopic versus open surgery in elderly patients with colorectal cancer: a retrospective multicenter study

BACKGROUND

Laparoscopic surgery is commonly used in elderly patients over 80 years old. The purpose of this study was to compare the perioperative and oncologic outcomes between laparoscopic surgery and open surgery in elderly patients with colorectal cancer.

METHODS

We retrospectively analyzed the medical records of patients aged ≥ 80 years who underwent curative resection of colorectal cancer at six Hallym University-affiliated hospitals. The perioperative outcomes and oncologic outcomes were compared between laparoscopic and open surgery RESULTS: Of 294 elderly patients, 104 (35.3%) underwent open surgery and 190 (64.7%) underwent laparoscopic surgery. The postoperative hospital stay (P = 0.019) and time to soft diet (P = 0.009) were shorter in the laparoscopic group than in the open group. Postoperative complications were less frequent in the laparoscopic group than in the open group (P < 0.001), including wound infection (P = 0.005), ileus (P = 0.005), and pneumonia (P = 0.001). The 3-year overall survival (OS) (P = 0.982) and recurrence-free survival rates (RFS) (P = 0.532) were similar in both groups. In multivariable analyses, positive lymph node status was the only independent factor associated with OS (P = 0.019) and RFS (P = 0.012). Laparoscopic surgery was not associated with OS (P = 0.874) and RFS (P = 0.772).

CONCLUSION

Laparoscopic surgery offers several perioperative advantages over open surgery and similar long-term oncological outcomes for elderly patients with colorectal cancer. Therefore, we suggest that laparoscopic surgery can be safely performed for the treatment of elderly patients (≥ 80 years old) with colorectal cancer.

Oncologic and survival outcomes in elderly patients with locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy and total mesorectal excision

BACKGROUND

The efficacy of the addition of neoadjuvant chemotherapy to neoadjuvant chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer in elderly patients has not been established.

METHODS

A total of 3096 locally advanced rectal cancer patients who received neoadjuvant chemotherapy, along with neoadjuvant chemoradiotherapy and total mesorectal excision, with or without adjuvant chemotherapy, between January 2010 and December 2018, were studied retrospectively. Patients were divided into elderly (>75 years) and younger (≤75 years) groups, and propensity score matching was used to balance a potentially confounding clinical bias. Overall survival, cancer-specific survival, disease-free survival, distant metastasis-free survival and local recurrence-free survival rates for the two groups were compared. Hazard ratios (HR) with 95% confidence intervals (CI) for different clinicopathological variables were calculated to determine predictors of 3-year overall survival.

RESULTS

Mean follow-up was 39.0 (range, 5-140) months. The overall 3-year overall survival, cancer-specific survival, disease-free survival, distant metastasis-free survival and locoregional relapse-free survival rates were 86.1, 87.6, 80.0, 82.4 and 95.4%, respectively. Only 3-year overall survival rates differed significantly between the elderly (77.2%) and younger (88.9%) groups (P = 0.01). Cancer-specific survival, disease-free survival, distant metastasis-free survival and locoregional relapse-free survival rates did not differ significantly between the two groups. Significant negative independent prognostic factors for 3-year overall survival were age >75 years (HR = 2.016, 95% CI 1.157-23.511, P = 0.01) and high pathologic TNM stage (yp stage III, P < 0.001).

CONCLUSION

For elderly locally advanced rectal cancer patients who have good health and performance status, the addition of neoadjuvant chemotherapy to neoadjuvant chemoradiotherapy and total mesorectal excision can result in disease-related survival rates and oncological outcomes similar to those experienced by younger patients. The decision to use this treatment approach in elderly patients should not be based solely on chronological age.

Association Between 5-Item Modified Frailty Index and Short-term Outcomes in Complex Head and Neck Surgery

OBJECTIVES

To evaluate the impact of preoperative frailty on short-term outcomes following complex head and neck surgeries (HNSs).

STUDY DESIGN

Cross-sectional database analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

The 2005 to 2017 ACS-NSQIP was queried for patients undergoing complex HNS. Five-item modified frailty index (mFI) was calculated based on functional status and history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and chronic hypertension.

RESULTS

A total of 2786 patients (73.1% male) with a mean age of 62.0 ± 11.6 years were included. Compared to nonfrail patients (41.2%), patients with mFI ≥1 (58.8%) had shorter length of operation (P = .021), longer length of stay (LOS) (P < .001), and higher rates of 30-day reoperation (P = .009), medical complications (P < .001), discharge to nonhome facility (DNHF) (P < .001), and mortality (P = .047). These parameters remained statistically significant when compared across all individual mFI scores (all P < .05). After adjusting for age, sex, race, body mass index, smoking, and American Society of Anesthesiologists score via multivariate logistic regression, patients with mFI ≥1 were significantly more likely to undergo reoperation (odds ratio [OR], 1.39), surgical complications (OR, 1.19), medical complications (OR, 1.55), prolonged LOS (OR, 1.29), and DNHF (OR, 1.56) (all P < .05). Multivariate logistic regression also demonstrated that after adjusting for confounders, compared to patients with mFI = 1, patients with mFI = 2-5 (18.7%) were more likely to undergo shorter operations (OR, 0.74), have medical (OR, 1.46) or any complications (OR, 1.27), and have DNHF (OR, 1.62) (all P < .05).

CONCLUSION

The 5-point mFI can independently predict short-term surgical outcomes following complex HNS. This simple and reliable metric can potentially lead to improved preoperative counseling and postoperative planning for complex HNS patients.

C-reactive protein/albumin ratio predicts survival after curative surgery in elderly patients with colorectal cancer

Inflammation-based markers, including the C-reactive protein/albumin ratio (CAR), lymphocyte/monocyte ratio (LMR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), Onodera's prognostic nutritional index (PNI), and Glasgow Prognostic Score (GPS), have been demonstrated to serve as prognostic indicators in various malignancies. This study aimed to evaluate their potential predictive value for colorectal cancer (CRC) in the elderly. We retrospectively evaluated 163 patients with CRC, aged 80 years and older, who had undergone curative surgery. The receiver operating characteristic curve analyses and the corresponding areas under the curve (AUCs) were used to determine and compare the discriminatory ability of the inflammation-based markers. Besides, the associations of inflammatory markers and clinical characteristics with overall survival (OS), relapse-free survival (RFS), and cancer-specific survival (CSS) were analyzed. The CAR had a significantly larger AUC than the GPS, PLR, NLR, and LMR (p = 0.006, 0.012, 0.018, and 0.002, respectively), except for the PNI (p = 0.052). The optimal cut-off value was 0.106 for the CAR and 44.894 for the PNI. Moreover, a CAR ≥ 0.106 turned out to be significantly associated with worse 5-year OS, RFS, and CSS compared with a CAR < 0.106. The multivariate analysis indicated that the CAR ≥ 0.106 was an independent prognostic factor for poor OS (HR = 3.596, p = 0.0006), RFS (HR = 2.945, p = 0.003), and CSS (HR = 4.411, p = 0.02). CAR is a useful and promising prognostic marker in elderly patients undergoing curative surgery for CRC.

Estimated global cancer incidence in the oldest adults in 2018 and projections to 2050

Using GLOBOCAN estimates, we describe the estimated cancer incidence among adults aged 80 years or older at the regional and global level in 2018, reporting the number of new cancer cases, and the truncated age-standardised incidence rates (per 100 000) for all cancer sites combined for this age group. We also presented the five most frequent cancers diagnosed by region and globally among females and males aged 65 to 79 years old and 80 years or older. We, finally, estimated the number of new cancer cases in 2050, the proportion of cases aged 80 years or older, and the proportional increase between 2018 and 2050 by region, by applying population projections to the 2018 incidence rates. In 2018, an estimated 2.3 million new cancer cases (excluding nonmelanoma skin cancers) were aged 80 years or older worldwide (13% of all cancer cases), with large variation in the profiles at regional levels. Globally, breast, lung and colon were the most common cancer sites diagnosed in the oldest females, while prostate, lung and colon were most frequent in the oldest males. In 2050, an estimated 6.9 million new cancers will be diagnosed in adults aged 80 years or older worldwide (20.5% of all cancer cases). Due to the complexity of cancer management in the oldest patients, the expected increase will challenge healthcare systems worldwide, posing a tangible economic and social impact on families and society. It is time to consider the oldest population in cancer control policies.

The Role of Radiation Therapy in the Older Patient

PURPOSE OF REVIEW

Older patients represent a unique subgroup of the cancer patient population for which the role of radiation therapy (RT) requires special consideration. This review will discuss many of these considerations as well as various radiation treatment techniques in the context of a variety of disease sites.

RECENT FINDINGS

Several recent studies give insight into the management of older cancer patients considering their age, performance status, comorbid conditions, quality of life, genetics, cost, and individual goals. RT plays an evolving and pivotal role in providing optimal care for this population. Recent advances in RT technique allow for more precise treatment delivery and reduced toxicity. Studies evaluating the use of radiation therapy in breast, brain, lung, prostate, rectal, pancreatic, esophageal, and oligometastatic cancer are summarized and discussed in the context of treating the older patient population. Individual age, performance and functional status, comorbid conditions, and patients' objectives and goals should all be considered when presenting treatment options for older patients and age alone should not disqualify patients from curative intent treatments. When possible, hypofractionated courses should be utilized as outcomes are often equivalent and toxicities are reduced. In many cases, RT may be preferable to other treatment options due to decreased toxicity profile and acceptable disease control.

Adherence to neoadjuvant therapy guidelines for locally advanced rectal cancers in a region with sociodemographic disparities

BACKGROUND

Practice guidelines recommend neoadjuvant chemoradiation (NCR) for locally advanced rectal cancer (LARC). We examined guideline adherence in a healthcare system serving a region with socioeconomic disparities and poor cancer outcomes.

METHODS

Retrospective analysis of factors associated with guideline adherence.

RESULTS

63.1% of stage II/III LARC patients received NCR. Factors associated with adherence included white race (OR = 2.15, p = 0.024), private insurance (OR = 2.70, p = 0.005), employed status (OR = 2.30, p = 0.031), age at diagnosis (OR = 0.74, p = 0.032), appropriate local staging (OR = 9.17, p < 0.0001), and diagnosis later in the study period (OR per 1 year = 1.20, p = 0.006). By multivariate analysis, private insurance (OR = 2.51, p = 0.023), younger age (OR per 10 years = 0.72, p = 0.048) and appropriate local staging (OR = 6.67, p < 0.0001) were associated with adherence.

CONCLUSION

Guideline adherence for LARC in our system is low and is impacted by employment, race and insurance status. Standard of care compliance remains an important target for improvement efforts in this underserved region of the nation's Mid-South.

The American College of Surgeons Geriatric Surgery Verification Program and the Practicing Colorectal Surgeon

The population is aging and older adults are increasingly undergoing surgery. Colorectal surgeons need to understand the risks inherent in the care of older adults and identify concrete ways to improve the quality of care for this vulnerable population. Goals for the practicing colorectal surgeon include: 1) introduce the American College of Surgeons’ (ACS) Geriatric Surgery Verification (GSV) Program and understand the intersection with colorectal surgery, 2) examine the 30 evidence-based GSV standards and how they can achieve better outcomes after colorectal surgery, and 3) outline the value and benefits for colorectal surgeons of implementing such a program.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review

PURPOSE

The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms.

METHODS

We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability.

RESULTS

Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%).

CONCLUSION

Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands

AIM

The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population.

METHODS

Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL.

RESULTS

Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS.

CONCLUSION

This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery.

Prognostic value of the preoperative prognostic nutritional index in oldest-old patients with colorectal cancer

BACKGROUND

The prognostic nutritional index (PNI), which is calculated using serum albumin and the peripheral lymphocyte count, is a simple and useful score for predicting the prognosis in patients with various cancers. The correlation between the preoperative PNI and long-term outcomes is unclear in oldest-old patients with colorectal cancer.

METHODS

A total of 84 consecutive patients ≥ 85 years old who underwent resection for primary colon adenocarcinoma at our institution between April 2008 and March 2017 were retrospectively reviewed. The cut-off value of the PNI for predicting the relapse-free survival (RFS) was 42.4 on a receiver operating characteristic curve analysis. The clinical characteristics and markers of systemic inflammation were then compared between patients with a low PNI (PNI < 42.4, n = 33) and a high PNI (PNI ≥ 42.4, n = 51).

RESULTS

A low PNI was associated with systemic inflammation marker levels, including a low neutrophil-to-lymphocyte ratio (p = 0.048), a low platelet-to-lymphocyte ratio (p = 0.006), and a high lymphocyte-to-monocyte ratio (p < 0.001). The median follow-up period of this cohort was 34 months (1-151 months). The 5-year RFS, overall survival (OS), and cancer-specific survival were significantly worse in the low-PNI group than in the high-PNI group (p = 0.032, p = 0.004, p = 0.049, respectively). In the multivariate analysis, a low PNI was an independent predictor for both the RFS (HR 3.188, p = 0.041) and OS (HR 3.953, p = 0.027).

CONCLUSIONS

A low-preoperative PNI was significantly associated with a poor prognosis in oldest-old colorectal cancer patients. Perioperative nutritional support may be important for prolonging the survival.

Oncologic Outcome and Morbidity in the Elderly Rectal Cancer Patients After Preoperative Chemoradiotherapy and Total Mesorectal Excision: A Multi-institutional and Case-matched Control Study

OBJECTIVE

To determine the toxicity and oncologic outcome of neoadjuvant chemoradiotherapy (CRT) followed by curative total mesorectal excision (TME) in the elderly (≥70 yrs) and younger (<70 yrs) rectal cancer patients.

BACKGROUND

Sufficient data for elderly rectal cancer patients who received definitive trimodality have not been accumulated yet.

PATIENTS AND METHODS

A total of 1232 rectal cancer patients who received neoadjuvant CRT and TME were enrolled in this study. After propensity-score matching, 310 younger patients and 310 elderly patients were matched with 1:1 manner. Treatment response, toxicity, surgical outcome, recurrence, and survival were assessed and compared between the 2 groups of patients.

RESULTS

The median age was 58 years for the younger patient group and 74 years for the elderly group. Pathologic complete response rates were not significantly different between the 2 groups (younger and elderly: 17.1% vs 14.8%, P = 0.443). The 5-year recurrence-free survival (younger and elderly: 67.7% vs 65.5%, P = 0.483) and overall survival (younger and elderly: 82.9% vs. 79.5%, P = 0.271) rates were not significantly different between the 2 groups either. Adjuvant chemotherapy after surgery was less frequently delivered to the elderly than that to younger patients (83.9% vs 69.0%). Grade 3 or higher acute hematologic toxicity was observed more frequently in the elderly than that in the younger group (9.0% vs 16.1%, P = 0.008). Late complication rate was higher in the elderly group compared with that in the younger group without statistical significance (2.6% vs 4.5%, P = 0.193).

CONCLUSIONS

Although acute hematologic toxicity was observed more frequently in the elderly patients than that in the younger patients, elderly rectal cancer patients with good performance status who received preoperative CRT and TME showed favorable tumor response and recurrence-free survival similar to younger patients.

Perceptions of aging and ageism among Mexican physicians-in-training

INTRODUCTION

Attributing negative stereotypes to older adults (ageism) may lead to undertreatment, but little is known about the prevalence of ageism among physicians treating patients with cancer in Ibero-America. We studied stereotypes of aging among Mexican physicians-in-training.

MATERIALS AND METHODS

Physicians-in-training attending an oncology meeting answered the "Negative Attributes and Positive Potential in Old Age" survey. Ten questions assessed positive characteristics of aging (PPOA; score 1-4, higher scores represent a positive perception), and four assessed negative characteristics (NAOA; score 1-4, higher score representing a negative perception). Descriptive statistics were used to analyze the questionnaires. Participants completed the "Image-of-Aging" question by writing five words describing older adults and young individuals. Each word was rated from - 5 (negative) to + 5 (positive), and presented as word clouds.

RESULTS

One hundred physicians-in-training (median age 28.5) were included. For the PPOA scale, the mean score was 2.9 (SD 0.4), while for the NAOA scale it was 2.1 (SD 0.4). Perceptions of aging were better among women and trainees enrolled in geriatrics and/or oncology-related programs. In the "Image-of-Aging" questions, median rating of words describing older adults was - 2, compared to + 3 for young individuals (p < 0.001). Among words used to describe older adults, the most frequent was "frail/frailty" (n = 45), while "health" (n = 46) was the most frequent for younger individuals.

CONCLUSIONS

Mexican physicians-in-training showed mostly negative perceptions of aging, exemplified by the use of negative terms to describe older adults. Creating educational initiatives aimed at decreasing ageism among oncology trainees is necessary across Ibero-America.

Global cancer incidence in older adults, 2012 and 2035: A population-based study

Population ageing has substantially contributed to the rising number of new cancer cases worldwide. We document cancer incidence patterns in 2012 among older adults globally, and examine the changing magnitude of cancer in this age group over the next decades. Using GLOBOCAN 2012 data, we presented the number and proportion of new cancer cases, and the truncated age-standardised incidence rates among adults aged 65 years and older for all cancer sites combined and for the five most common cancer sites by world region. We calculated the incidence in 2035 by applying population projections, assuming no changes in rates. In 2012, 6.7 million new cancer cases (47.5% of all cancers) were diagnosed among older adults worldwide, with marked regional disparities. Nearly 48% of these cases occurred in less developed regions. Lung, colorectal, prostate, stomach and breast cancers represented 55% of the global incidence, yet distinct regional patterns were observed. We predict 14 million new cancer cases by 2035, representing almost 60% of the global cancer incidence. The largest relative increase in incidence is predicted in the Middle East and Northern Africa (+157%), and in China (+155%). Less developed regions will see an increase of new cases by 144%, compared to 54% in more developed regions. The expected increase in cancer incidence at older ages will have substantial economic and social impacts globally, posing considerable and unique challenge to healthcare systems in every world region, especially in those with limited resources and weaker health systems.

Robotic Versus Laparoscopic Colorectal Cancer Surgery in Elderly Patients: A Propensity Score Match Analysis

BACKGROUND

Minimally invasive surgery in elderly patients with colorectal cancer remains controversial. The study aimed to compare the operative, postoperative, and oncologic outcomes of robotic (robotic colorectal resection surgery [RCRS]) versus laparoscopic colorectal resection surgery (LCRS) in elderly patients with colorectal cancer.

METHODS

Propensity score matching (PSM) was used to compare patients aged 70 years and more undergoing elective RCRS or LCRS for colorectal cancer between 2010 and 2017.

RESULTS

Overall, 160 patients underwent elective curative LCRS (n = 102) or RCRS (n = 58) for colorectal cancer. Before PSM, the mean preoperative Charlson score and the tumor size were significantly lower in the robotic group. After matching, 43 RCRSs were compared with 43 LCRSs. The RCRS group showed longer operative times (300.6 versus 214.5 min, P = .03) compared with LCRS, but all other operative variables were comparable between the two groups. No differences were found for postoperative morbidity, mortality, time to flatus, return to regular diet, and length of hospital stay. R0 resection was obtained in 95.3% of procedures. The overall and disease-free survival rates at 1, 2, and 3 years were similar between RCRS and LCRS patients. The presence of more than one comorbidity before surgery was significantly associated with the incidence of postoperative complications.

CONCLUSION

In patients aged 70 years or more, robotic colorectal surgery showed operative and oncologic outcomes similar to those obtained by laparoscopy, despite longer operative times. Randomized trials are awaited to reliably assess the clinical and oncological noninferiority and the costs/benefits ratio of robotic colorectal surgery in elderly populations.

Morbidity, mortality, and survival in elderly patients undergoing pulmonary metastasectomy for colorectal cancer

PURPOSE

The number of elderly patients with colorectal cancer is increasing. Nevertheless, they are undertreated compared to younger patients. This study compares postoperative morbidity, mortality, survival, and morbidity risk factors of elderly and younger patients undergoing pulmonary metastasectomy (PM).

METHODS

We retrospectively analyzed our prospective database of 224 patients operated for colorectal lung metastases between 1999 and 2014. Two groups were defined to evaluate the influence of the patients' age (A: < 70 years; B: ≥ 70 years). Morbidity, mortality, and risk factors for morbidity were analyzed using χ²-test and Fisher's exact test. The Kaplan-Meier method, log-rank test, and multivariate Cox regression were used to assess survival and prognosticators.

RESULTS

Altogether, minor morbidity, major morbidity, and mortality were 17%, 5.8%, and 0%, respectively. Between groups A (n = 170) and B (n = 54), there was no difference in minor and major morbidity (p = 0.100) or mortality (0%). Heart arrhythmia was a risk factor for increased morbidity in group B (p = 0.007). The 5-, 10-, and 15-year survival rates were 43%, 30%, and 27%, respectively, in group A and 55%, 36 and 19%, respectively, in group B (p = 0.316). Disease-free interval ≥ 36 months (p = 0.023; OR 2.88) and anatomic resections (p = 0.022; OR 3.05) were associated with prolonged survival in elderly patients.

CONCLUSIONS

Morbidity, mortality, and overall survival after PM with lymphadenectomy for elderly patients were comparable to younger patients. A disease-free interval > 36 months and anatomic lung resections might be associated with prolonged survival. However, elderly patients should also be evaluated for a curative treatment.

Long-Term Survival in Octogenarians After Surgical Treatment for Colorectal Cancer: Prevention of Postoperative Complications is Key

Background

Whether to treat octogenarians with colorectal cancer (CRC) in the same manner as younger patients remains a challenging issue. The purpose of this study was to analyse postoperative complications and long-term survival in a consecutive cohort of octogenarians who were surgically treated for CRC.

Methods

Octogenarians with primary CRC suitable for curative surgery between January 2008 and December 2011 were included. Data about comorbidities, tumour stage, and complications were retrospectively collected from patient files. Data about survival were retrieved with use of the Dutch database for persons and addresses. To identify factors associated with severe postoperative complications and postoperative survival, logistic regression analyses, and Cox regression analyses were performed. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CI) were estimated.

Results

In a series of 108 octogenarians, median age was 83 years (range 80–94 years). Median follow-up was 47 (range 1–107) months. Major postoperative complications occurred in 25% of the patients. No risk factors for development of severe postoperative complications could be identified. The 30-day mortality was 7%; 1- and 5-year mortality was 19% and 56%, respectively. Overall median survival was 48 months: 66 months in patients without complications versus 13 months in patients with postoperative complications. Postoperative complications were most predictive of decreased survival (HR 3.16; 95% CI 1.79–5.59), even including tumour characteristics, comorbidity, and emergency surgery.

Conclusions

Long-term survival in octogenarians deemed fit for surgery is reasonably good. Prevention of major postoperative complications could further improve clinical outcome.

Oncologic outcome of colorectal cancer patients over age 80: a propensity score-matched analysis

PURPOSE

It remains unclear whether old age is a poor prognostic factor in colorectal cancer (CRC). We compared oncologic outcomes in CRC patients according to age, using 80 as the dividing point.

METHODS

CRC patients who underwent radical surgery from 2000 to 2011 were evaluated. We performed matched and adjusted analyses comparing oncologic outcomes between patients with ≥ 80 and < 80 years old.

RESULTS

Among 9562 patients, 222 were elderly. The median age was 82.0 years in elderly patients and 59.0 years in young patients. Elderly patients received less neoadjuvant or adjuvant therapy compared to young patients (p < 0.001). After recurrence, significantly fewer elderly patients received additional treatments (p < 0.001). Before matching, disease-free survival (DFS) and cancer-specific survival (CSS) were significantly lower for elderly patients compared to those for young patients (p < 0.001 and p < 0.001, respectively). After matching, DFS and CCS were not significantly different between the two groups (p = 0.400 and p = 0.267, respectively). In a multivariate analysis for prognostic factors, old age was not an independent poor prognostic factor of DFS and CCS (p = 0.619 and p = 0.137, respectively).

CONCLUSIONS

Elderly patients aged ≥ 80 years with CRC had similar oncologic outcome to young patients, and age was not an independent prognostic factor.

Causes of mortality in older patients with stage 3 colon cancer

OBJECTIVES

Life expectancy plays a key role in the selection of patients with stage III colon cancer for adjuvant chemotherapy, but little is known about causes of mortality in older patients with colon cancer. We aimed to examine causes of death in this population and compare these causes between patients who received chemotherapy and those who did not. Specifically, we chose to examine the rates of death related to recurrent colon cancer versus non colon cancer.

MATERIALS AND METHODS

Patients aged 50 and older diagnosed with stage III colon cancer between 2005 and 2009 were included. Patients were divided into "younger" (aged 50-69) and "older" (aged 70+). Causes of death, which were categorized into colon cancer versus non-colon cancer related.

RESULTS

1361 patients were included, 50% of whom were 70 or older. Younger patients were more likely to receive adjuvant chemotherapy (90% vs. 60%). 601 patients died in the follow up period. Deceased patients in the younger group were more likely to die from colon cancer (81% vs. 62%). The most common cause of non-colon cancer death was other primary malignancies in younger patients and cardiovascular diseases in older patients. In older patients who received chemotherapy, 41% died; 89% of these deaths were related to colon cancer. In older patients who did not receive chemotherapy 72% died, with 38% of patients ultimately dying from colon cancer.

CONCLUSIONS

Older patients remain under-treated with chemotherapy. Although non-colon cancer deaths were more frequent in older patients with cancer, colon cancer was a still a significant cause of mortality. These deaths may be preventable with adjuvant chemotherapy.

Management of locally advanced rectal cancer in the elderly: a critical review and algorithm

Colorectal cancer incidence and death rates have been declining over the past 10 years. However, it remains the second leading cause of death in men ages 60-79 and the third leading cause of death in men over 80 and in women over 60 years old. However, there is little data specific to the treatment of the elder patient, since few of these patients are included in trials. With the advent of improved therapies, there are many alternative options available. Still, no definitive consensus or guidelines have been defined for this particular patient population. The goal of this study is to review the literature on the management of rectal cancer in the elderly and to propose treatment algorithms to help the oncology team in treatment decision-making.

Decision-Making Strategy for Rectal Cancer Management Using Radiation Therapy for Elderly or Comorbid Patients

Rectal cancer predominantly affects patients older than 70 years, with peak incidence at age 80 to 85 years. However, the standard treatment paradigm for rectal cancer oftentimes cannot be feasibly applied to these patients owing to frailty or comorbid conditions. There are currently little information and no treatment guidelines to help direct therapy for patients who are elderly and/or have significant comorbidities, because most are not included or specifically studied in clinical trials. More recently various alternative treatment options have been brought to light that may potentially be utilized in this group of patients. This critical review examines the available literature on alternative therapies for rectal cancer and proposes a treatment algorithm to help guide clinicians in treatment decision making for elderly and comorbid patients.

Optimal oncologic treatment of rectal cancer in patients over 75 years old: Results of a strategy based on oncogeriatric evaluation

BACKGROUND

Few data are available on the management of elderly rectal cancer patients, and especially on the ability to provide optimal oncological treatment. The aim of this study was to determine the feasibility and results of multimodality treatment for rectal cancer in patients 75years and older after simplified comprehensive geriatric assessment (CGA) according to Balducci score.

METHODS

We reviewed the charts of elderly patients who underwent surgery for localized middle or low rectal cancer. Patients were classified into three CGA groups depending on their functional reserve, comorbidities, geriatric syndromes, and life expectancy.

RESULTS

Neoadjuvant therapy was discussed for 27 patients (47%), but only 56% of them were treated, including 8, 7, and 1 patient from CGA groups 1, 2, and 3, respectively. Fifty-three patients (93%) underwent sphincter-preserving surgical resection and four patients underwent abdominoperineal resection (7%). Postoperative complications were observed in 21 patients (37%). The postoperative complication rate was correlated non-significantly with age (<85years: 40.6%; ≥85years: 57.1%; P=0.3), and with the CGA (P=0.64). In total, 10 patients (18%) had definitive colostomy, including five anastomotic leakages (9%), and one incontinence (2%). The total rate of sphincter preservation was 82% (n=47). The risk of secondary definitive colonic stoma formation was not correlated with CGA (group 1: 14%; group 2/3: 16%; P=0.8). Estimated OS at five years was 52%.

CONCLUSIONS

After routine geriatric assessment, elderly rectal cancer patients have good rates of sphincter conservation and acceptable morbidity/mortality.

Radical Treatment of Rectal Cancer in Elderly Is Feasible than Feared: Results from a Tertiary Care Centre

The thought of subjecting an elderly patient with rectal cancer to protocol-based neoadjuvant chemoradiation (NACTRT), surgery and adjuvant chemotherapy is sought with fear due to their multiple comorbidities and impaired functional status associated with the process of ageing. Hence, many a times the treatment is compromised and it is a fact that this subgroup of patients is underrepresented in most of the clinical trials. This study was aimed at analysing the perioperative and oncologic outcomes after protocol-based treatment of rectal cancer in the elderly patients, defined here as those with age ≥70 years. Prospective analysis of medical records of rectal cancer patients was done who were ≥70 years of age and were diagnosed and treated at Regional Cancer Centre (RCC), Thiruvanathapuram from 2008 to 2012. In this 5-year period, a total of 339 rectal cancer patients underwent surgery as part of multimodality treatment with curative intent. Of them, 75 patients were ≥70 years of age. Half of them had one or more comorbidities (54%) and majority were locally advanced at presentation (77%). Forty-seven (62%) cases received NACTRT and all of them tolerated RT dose (50.4 Gy) without modification. Anterior resection (AR) was performed in 48 (64%) and abdominoperineal resection (APR) in remaining. Diverting stoma was made in four; of which three remained permanent. Two colostomies were performed for delayed leaks. Three patients (4%) died within 30 days due to leak, sepsis and cardiopulmonary causes. Two thirds (49/75) received adjuvant chemotherapy (ACT) but only 55% of them (27/49) could complete all the cycles without dose modification. The median survival was 28 months. The 3-year disease-free survival (DFS) and overall (OS) were 80.1 and 83.9%, respectively. There were 11 distant recurrences including two locoregional recurrences. The morbidity and mortality of multimodality therapy is reasonable to proceed with radical treatment with curative intent in the elderly patients with rectal cancer.

Impact of age on efficacy of postoperative oxaliplatin-based chemotherapy in patients with rectal cancer after neoadjuvant chemoradiotherapy

Background

Clinical practice guidelines focusing on age-related adjuvant chemotherapy for rectal cancer are currently limited. The present study aimed to explore the impact of age on the efficacy of adjuvant oxaliplatin-based chemotherapy in patients with rectal cancer after neoadjuvant chemoradiotherapy.

Methods

We performed a retrospective cohort analysis using data from the Surveillance, Epidemiology, and End Results-Medicare-linked database from 1992–2009. We enrolled patients with yp stages I–III rectal cancer who received neoadjuvant chemoradiotherapy and underwent curative resection. The age-related survival benefit of adding oxaliplatin to adjuvant 5-fluorouracil (5-FU) chemotherapy was evaluated using Kaplan–Meier survival analysis with propensity score-matching and Cox proportional hazards models.

Results

Comparing the oxaliplatin group with the 5-FU group, there were significant interactions between age and chemotherapy efficacy in terms of overall survival (OS) (p for interaction = 0.017) among patients with positive lymph nodes (ypN+). Adding oxaliplatin to 5-FU could prolong survival in patients aged < 73 years and ypN+ category, and but did not translate into survival benefits in patients aged ≥ 73 years and ypN+ category. No significant interactions were observed among ypN− patients, and oxaliplatin did not significantly improve OS, regardless of age.

Conclusions

In patients with rectal cancer who have already received neoadjuvant chemoradiotherapy and undergone curative resection, adding oxaliplatin to 5-FU could prolong OS in patients aged < 73 years and ypN+ category. However, adding oxaliplatin did not translate into survival benefits in patients age ≥ 73 years and ypN+ category, or in ypN− patients.

Health care disparities among octogenarians and nonagenarians with stage II and III rectal cancer

BACKGROUND

Octogenarians and nonagenarians with stage II/III rectal adenocarcinomas are underrepresented in the randomized trials that have established the standard-of-care therapy of preoperative chemoradiation followed by definitive resection (ie, chemoradiation and then surgery [CRT+S]). The purpose of this study was to evaluate the impact of therapies on overall survival (OS) for patients with stage II/III rectal cancers and determine predictors of therapy within the National Cancer Data Base (NCDB).

METHODS

In the NCDB, patients who were 80 years old or older and had clinical stage II/III rectal adenocarcinoma from 2004 to 2013 were queried. Kaplan-Meier analysis, log-rank testing, logistic regression, Cox proportional hazards regression, interaction effect testing, and propensity score-matched analysis were conducted.

RESULTS

The criteria were met by 2723 patients: 14.9% received no treatment, 29.7% had surgery alone, 5.0% underwent short-course radiation and then surgery (RT+S), 45.3% underwent CRT+S, and 5.1% underwent surgery and then chemoradiation (S+CRT). African American race and residence in a less educated county were associated with not receiving treatment. Male sex, older age, worsening comorbidities, and receiving no treatment or undergoing surgery alone were associated with worse OS. There was no statistical difference in OS between RT+S, S+CRT, and CRT+S. Interaction testing found that CRT+S improved OS independently of age, comorbidity status, sex, race, and tumor stage. In the propensity score-matched analysis, CRT+S was associated with improved OS in comparison with surgery alone.

CONCLUSIONS

A significant portion of octogenarians and nonagenarians with stage II/III rectal adenocarcinomas do not receive treatment. African American race and living in a less educated community are associated with not receiving therapy. This series suggests that CRT+S is a reasonable strategy for elderly patients who can tolerate therapy. Cancer 2017;123:4325-36. © 2017 American Cancer Society.

Surgery for colorectal cancer in elderly patients: how can we improve outcome?

PURPOSE

Patients over 70 years of age are characterised by diminished long-term survival rates following resection of colorectal cancer (CRC) compared to younger patients. The aim of this study was to clarify whether reduced survival is a result of malignancy, comorbidities or the treatment received.

METHODS

All patients with CRC, who were admitted to our institution over a period of 10 years, were selected from a prospectively maintained database. Disease-specific, disease-free and overall survival rates were calculated dependent on variables considered potentially relevant for the patients' prognosis.

RESULTS

915 patients were included in the study. Observed 5- and 10-year survival rates for the whole group were 48 ± 2% and 40 ± 2%, respectively, but 10-year survival rates dropped to 14 ± 4% for patients aged 80 and older. Resection of the primary tumour was attempted in all cases independent of age. Emergency admission, Charlson index ≥2, ECOG ≥2, old age, second malignancies, distant metastases, high grading and non-resective surgery were identified as independent prognostic parameters associated with decreased overall survival. In contrast, disease-specific and disease-free survival rates for patients after elective radical resection in UICC-stage I-III did not show significant differences related to age. Tumour site, UICC-stage and resection status were independent statistically significant predictors of disease-specific survival.

CONCLUSIONS

Similar disease-specific survival rates in all age groups speak in favour of tumour resection in curative intent even in old patients. Better outcome may be achieved, if regular screening for colorectal cancer is considered even in the elderly to avoid late presentation requiring emergency surgery.

The First Year After Colorectal Surgery in the Elderly

Purpose

Surgery for colorectal malignancy is increasingly being performed in the elderly. Little is known about the impact of complications on late mortality. This study aimed to analyze whether a complicated postoperative course affects the 1-year survival in elderly patients.

Methods

All consecutive patients older than 75 years of age who underwent colorectal cancer surgery between January 2009 and April 2013 were included in this study. The main outcome was mortality at 1 year after surgery. Logistic regression analyses were performed to determine risk factors for a poor outcome (mortality) after survival of the early postoperative course of surgery at 1-year follow-up. Patients who died within 30 days postoperatively were excluded from analysis.

Results

The early mortality rate was 6.3% (n = 15), and 2 patients died during follow-up as a result of complications after a second surgery. A total of 223 patients survived the perioperative period and were included in this study. Twenty-two patients (9.9%) died during the first year of follow-up. Stage IV disease (P = 0.002), complications of primary surgery (P = 0.016), and comorbidity (P = 0.050) were risk factors for 1-year mortality. Intensive care unit stay, reoperation and readmission were not associated with a worse 1-year outcome.

Conclusion

Elderly patients with stage IV disease at the time of surgery, comorbidity, and postoperative complications are at risk for mortality during the first year after surgery. A patient-tailored approach with special attention to perioperative care should be considered in the elderly.

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.

[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]

Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.