Colorectal cancer outcomes in patients aged over 85 years

Postoperative Course and Supportive Care in Very Elderly Cecum Cancer Patients

In developed countries like Japan, the size of the older population is rapidly increasing. Malignant neoplasms rank as the leading cause of death among the geriatric population of Japan, emphasizing the rising demand for cancer care in this demographic. Older patients, besides facing physical and cognitive challenges, are also affected by their social environment, necessitating tailored interventions. Few case reports have detailed the progress of cancer treatment in nonagenarian patients. This study presents the progress of two very old patients with cancer. The first case, a 95-year-old female with chronic constipation underwent emergency surgery for a cecal tumor. Despite initial improvements, her mobility declined after surgery, leading to institutionalization. Recurrent hospitalizations ensued with complications culminating in her death approximately 20 months after surgery. In the second case, a 94-year-old male, initially declining aggressive treatment for a suspected ileocecal malignancy, later opted for supportive care. Despite stable conditions, he eventually died at home after experiencing progressive weakness, which was approximately 20 months after the initial diagnosis. These cases shed light on the management of elderly patients with ileocecal cancer, illustrating the divergent trajectories between surgical intervention and supportive care. The tumor did not recur in the patient who underwent surgery; however, the independence in performing daily living activities declined significantly. In the case managed with the best-supportive care, progression was slow; however, severe anemia became a concern toward the end of life.

Circular RNA circNCOA3 promotes tumor progression and anti-PD-1 resistance in colorectal cancer

Aim: Circular RNAs (circRNAs) have been found to be involved in tumor progression, but their role in colorectal cancer (CRC) immune escape remains to be elucidated. Methods: circRNAs differentially expressed in responsive and resistant CRC tissues to programmed cell death 1 (PD-1) antibody therapy were identified by microarray analysis. The clinical and pathological significance of circNCOA3 was validated in a separate cohort of CRC samples. The function of circNCOA3 was explored experimentally. RNA immunoprecipitation and luciferase activity assays were conducted to identify downstream targets of circNCOA3. Results: The circNCOA3 was markedly overexpressed in CRC samples resistant to PD-1 blockade. circNCOA3 expression was significantly correlated with adverse tumor phenotypes and poor outcomes in CRC patients. Knockdown of circNCOA3 expression markedly suppressed the proliferative and invasive capability of CRC cells. Moreover, knockdown of circNCOA3 increased the proportion of CD8+ T cells while decreasing the proportion of myeloid-derived suppressor cells (MDSCs). Knockdown of circNCOA3 inhibited tumor growth and increased the sensitivity to PD-1 antibody treatment in mouse tumor models. Further studies revealed that circNCOA3 acted as a competing endogenous RNA (ceRNA) for miR-203a-3p.1 to influence the level of CXCL1. Conclusion: Our findings indicate that circNCOA3 might be useful as a potential biomarker to predict the efficacy and prognosis of CRC patients treated with anti-PD-1 therapy.

Colorectal cancer surgery in octogenarians: real-world long-term results

AIMS

Colon cancer is the most common intra-abdominal cancer in older people. In the elderly with cancer, clinical decision making is often complicated by the effects of aging. However, as life expectancy continues to rise, more people aged 80 and older will present with colorectal cancer and may need major surgery.

METHODS

Between 2000 and 2020 we operated on 352 patients aged 80 and older for colorectal cancer. We reviewed the case-notes of these patients and made a survival analysis for those patients who had a surgical resection of the tumor.

RESULTS

In 20 patients a palliative procedure was performed. Three hundred and thirty-two (332) patients had a colorectal cancer resected. Of these, 57 patients died within 90 days postoperatively. Survival analysis was done for 275 patients who were alive longer than 90 days postoperatively. The overall 5-year survival in this group is 41.5%. There was no significant difference in postoperative survival between patients over the age of 85 and patients aged 80-84 at the time of operation. The survival of patients with stage IV colorectal adenocarcinoma is significantly worse than survival in stage I-III patients (Cox-Mantel log-rank test p < 0.001).

CONCLUSIONS

After exclusion of the patients in the 90-day mortality group the overall 5-year survival in octogenarians who had a resection of a colorectal cancer was 41.5%. The most difficult problem is to choose the right treatment for the right patient. Optimal surgical and adjuvant treatment should not be denied to these older patients.

The effect of age on the opportunity to receive cancer treatment

INTRODUCTION

Older adults with cancer may not receive the same opportunities for treatment as younger patients. In this retrospective population-based cohort study, we explored whether age was an independent predictor of receiving specialist consultation and treatment.

METHODS

Patients age 45-99 were identified from the Ontario Cancer Registry having a primary solid tumor diagnosed between 01/Jan/2010 and 31/Dec/2019. We used logistic regression adjusted sociodemographic and clinical characteristics to compare the likelihood of consultation or receipt of treatment using linear splines at critical ages of 65, 80, and 90 years.

RESULTS

A total 168,232 (42%), 165,205 (41%), 57,360 (14%), and 7810 (2%) patients were diagnosed age 45-64, 65-79, 80-89, and 90-99, respectively. The likelihood of surgical consultation decreased as patients reached 65 years [adjusted odds ratio (aOR) 0.86 (0.84-0.89)], which decreased further among octogenarians [aOR 0.63 (0.59-0.67)]. Similar results were observed for consultation with a medical oncologist and radiation oncologist. Receipt of surgery also decreased with age. Three-month post-operative mortality was higher among older patients [aRR 1.38 (1.26-1.50) per 10 years, p < 0.0001], an effect that remained similar as patients reached age 65 + years of age (p = 0.09 for change). For stage I patients, 3-month post-operative survival was high across all age groups, ranging from 99.8% in 45-64 year-olds, 99.4% in 65-79 year-olds, and 98.1% among octogenarians and nonagenarians (lung, colorectal, breast, cervical cancer patients).

CONCLUSION

Older patients were less likely to have specialist consultations. More comprehensive data collection on clinical factors and referral patterns is needed to improve care for elderly cancer patients.

Laparoscopic surgery for colorectal cancer in an elderly population with high comorbidity: a single centre experience

PURPOSE

The use of laparoscopic surgery for colorectal cancer in elderly patients with high comorbidity is a controversial subject. This retrospective analysis aims to compare two different age groups with respect to short and long term clinical and oncological outcomes.

METHODS

All laparoscopic colorectal resections for cancer performed between February 2011 and October 2017 with curative or palliative intention were evaluated.

RESULTS

Among 128 completed resections, the rate of major complications, length of hospital stays, 30-day mortality, 2-year recurrence rate, and the survival after palliative surgery were comparable between group A (< 75 years; n = 76) and B (≥ 75 years; n = 52). Patients in group B showed an extraordinarily high proportion of ASA III stage (73.1% vs. A: 35.5%; p < 0.01) and, in this context, an increased rate of minor postoperative complications (17.3% vs. A: 6.6%; p < 0.05) and lower overall 2 and 5-year survival rates. Within the first 2 years, they died sooner in the event of recurrence (57.1% vs. A: 18.2%; p < 0.05), and their survival after rectal resection, especially for low rectal carcinoma, was significantly reduced (58.8% vs. A: 96.7%; p < 0.001).

CONCLUSION

Laparoscopic surgery for colorectal cancer can be strongly advocated for elderly patients even in the face of high comorbidity. Whether very old patients with low rectal carcinoma also benefit from minimally invasive surgery or should undergo alternative therapies would need to be clarified primarily by examining the quality of life.

The Safety and Clinical Validity of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients Aged More Than 85 Years

Endoscopic submucosal dissection (ESD) is a safe and minimally invasive method for the treatment of early gastric cancer (EGC). However, whether ESD for EGC is also safe and feasible in patients aged ≥85 years is unclear. The patients enrolled in this study were divided into three groups: age ≥85 years (44 patients, 49 lesions), age 65−84 years (624 patients, 687 lesions), and age ≤64 years (162 patients, 174 lesions). We evaluated the incidence of adverse events (AEs) and overall survival (OS) and disease-specific survival (DSS). We analyzed the factors that had a significant impact on the prognosis of patients aged ≥85 years. No significant differences were found in the incidence of AEs among the three groups (p = 0.612). The OS was significantly lower in patients aged ≥85 years (p < 0.001). Conversely, DSS was not significantly worse in patients aged ≥85 years (p = 0.100). The poor Geriatric Nutritional Risk Index correlated with poor prognosis in patients aged ≥85 years (p < 0.001). ESD is a safe and valid treatment for EGC in patients aged ≥85 years. However, the indications should be carefully decided because it is difficult to estimate the survival contribution of ESD for EGC in patients aged ≥85 years, especially in those with poor nutritional status.

Incidence of age migration of colorectal cancer in younger population: Retrospective single centred-population based cohort study

BACKGROUND

The positive correlation between the incidence of colorectal cancer and age is well known. However, current data demonstrates that there is noticeable age migration in the incidence of colorectal cancer towards young adults highlighting that this disease should no longer be considered to solely affect the elderly. The aim of the study is to analyse the changes in the trend for the age at which colorectal cancer presents, to identify if there is an appreciable age migration towards a younger population.

METHODS

This is a retrospective observational cohort study on a single-centred population. Data was obtained from The Luton and Dunstable University Hospital Colorectal Cancer Database. It was analysed from three separate decades from the years 1999, 2009, 2019 and 2020. All patients newly diagnosed with colorectal cancer in these time periods were included in this study. Gender, anatomical site, and the stage migration was also analysed.

RESULTS

A total of 598 patients were diagnosed with colorectal cancer in the specified time periods. The overall age-specific incidence rates had risen throughout the three decades. Notably the incidence rate had doubled between 1999 and 2009. In the younger adult population of <40 years, the incidence rate had risen seven-fold across three decades with a disproportionate increase among females compared to males. Stage migration is also analysed over the three decades with no evident difference in anatomical position of the tumour.

CONCLUSION

There has been an upwards trend in the incidence of colorectal cancer among the younger population. This will have implications for investigation and screening in the future.

T Cell Aging in Patients with Colorectal Cancer-What Do We Know So Far?

Simple Summary

This review describes the role of T cell aging in colorectal cancer development. T cells are important mediators in cancer immunity. Aging affects T cells, leading to various dysfunctions which can impede antitumor immunity. While some hallmarks of T cell aging have been observed in colorectal cancer patients, the functional role of such cells is not clear. Therefore, understanding how aged T cells influence overall patient outcome could potentially help in the pursue to develop new therapies for the elderly.

Abstract

Colorectal cancer (CRC) continues to be one of the most frequently diagnosed types of cancers in the world. CRC is considered to affect mostly elderly patients, and the number of diagnosed cases increases with age. Even though general screening improves outcomes, the overall survival and recurrence-free CRC rates in aged individuals are highly dependent on their history of comorbidities. Furthermore, aging is also known to alter the immune system, and especially the adaptive immune T cells. Many studies have emphasized the importance of T cell responses to CRC. Therefore, understanding how age-related changes affect the outcome in CRC patients is crucial. This review focuses on what is so far known about age-related T cell dysfunction in elderly patients with colorectal cancer and how aged T cells can mediate its development. Last, this study describes the advances in basic animal models that have potential to be used to elucidate the role of aged T cells in CRC.

Surgical outcomes following colorectal cancer resections in patients aged 80 years and over: results from the Australia and New Zealand Binational Colorectal Cancer Audit

AIM

The primary aim was to compare the 30-day morbidity and mortality in patients aged ≥80 years undergoing surgery for colorectal cancer with those aged <80 years. The secondary aim was to identify independent outcome predictors.

METHOD

This was a retrospective study of patients undergoing surgery for colorectal cancer between January 2007 and February 2018. Patients were divided into those <80 years and those ≥80 years at the time of surgery. Data had been collected prospectively by the Australasian Binational Colorectal Cancer Audit and included patient demographics, site and stage of tumour, comorbidity, operative details, American Society of Anesthesiologists score (ASA), pathological staging, 30-day mortality and morbidity (medical and surgical). Univariate and multivariate analyses were used to identify predictors of 30-day morbidity and mortality.

RESULTS

During the study period, 4600 out of 20 463 (22.5%) patients were ≥80 years. They had a greater 30-day mortality after both colonic (97/2975 [3.3%] vs. 66/7010 [0.9%], P < 0.001) and rectal resections (50/1625 [3.1%] vs. 36/9006 [0.4%], P < 0.001) compared with younger patients. They also had an increased length of stay (colon cancer, 9 vs. 7 days; rectal cancer, 10 vs. 8 days; P < 0.001) and medical complications (colon cancer, 23.5% vs. 12.7%; rectal cancer, 25.2% vs. 11.2%; P < 0.001). Surgical complications were equivalent. Age ≥80 years was not an independent predictor of 30-day morbidity or mortality. Patients ≥80 years who were ASA 2/3 and had rectal cancer seemed to fare worse in terms of 30-day mortality (ASA 2, 22%, 95% CI 9%-36%, P < 0.001; ASA 3, 11%, 95% CI 4%-19%, P< 0.001).

CONCLUSIONS

Postoperative morbidity and mortality are significantly greater in patients ≥80 years undergoing colorectal cancer surgery. Any recommendation for surgery in this age group should take into account patient comorbidity and not be based on age alone.

A 10-Year Probability Deep Neural Network Prediction Model for Lung Cancer

Cancer is the leading cause of death in Taiwan. According to the Cancer Registration Report of Taiwan's Ministry of Health and Welfare, a total of 13,488 people suffered from lung cancer in 2016, making it the second-most common cancer and the leading cancer in men. Compared with other types of cancer, the incidence of lung cancer is high. In this study, the National Health Insurance Research Database (NHIRDB) was used to determine the diseases and symptoms associated with lung cancer, and a 10-year probability deep neural network prediction model for lung cancer was developed. The proposed model could allow patients with a high risk of lung cancer to receive an earlier diagnosis and support the physicians' clinical decision-making. The study was designed as a cohort study. The subjects were patients who were diagnosed with lung cancer between 2000 and 2009, and the patients' disease histories were back-tracked for a period, extending to ten years before the diagnosis of lung cancer. As a result, a total of 13 diseases were selected as the predicting factors. A nine layers deep neural network model was created to predict the probability of lung cancer, depending on the different pre-diagnosed diseases, and to benefit the earlier detection of lung cancer in potential patients. The model is trained 1000 times, the batch size is set to 100, the SGD (Stochastic gradient descent) optimizer is used, the learning rate is set to 0.1, and the momentum is set to 0.1. The proposed model showed an accuracy of 85.4%, a sensitivity of 72.4% and a specificity of 85%, as well as an 87.4% area under ROC (AUROC) (95%, 0.8604-0.8885) model precision. Based on data analysis and deep learning, our prediction model discovered some features that had not been previously identified by clinical knowledge. This study tracks a decade of clinical diagnostic records to identify possible symptoms and comorbidities of lung cancer, allows early prediction of the disease, and assists more patients with early diagnosis.

Outcomes following emergency colorectal cancer presentation in the elderly

AIM

Colorectal cancer is predominantly a disease of the elderly and up to 30% of these patients will present as an emergency. We compared the outcomes of 'elderly' patients presenting to our unit with a colorectal cancer emergency over a 10-year period with those of a 'younger' cohort.

METHODS

A single centre retrospective review of colorectal cancer emergencies between 1 April 2007 and 1 April 2017 was performed. Patients were separated into two cohorts: 'young' (< 75 years) and 'elderly' (≥ 75 years). Data collected included demographics, disease status, treatment and outcomes.

RESULTS

A total of 341 patients (< 75 years: n = 154; ≥ 75 years: n = 187) presented as a colorectal cancer emergency. Significantly fewer 'elderly' patients underwent curative surgical procedures (72% vs 49%, P < 0.0001) or received adjuvant chemotherapy (56% vs 21%, P < 0.0001). 'Elderly' patients had significantly more postoperative cardio-respiratory complications (7% vs 36%, P < 0.0001), but despite this there was no significant difference in 30-day mortality (7% vs 12%) and survival rates at 1 year (75% vs 74%) or 3 years (56% vs 49%). Elderly patients treated with best supportive care had a median overall survival of just 62 (range 1-955) days.

CONCLUSION

Patients ≥ 75 years presenting as a colorectal cancer emergency were significantly less likely to undergo emergency curative surgery or receive adjuvant chemotherapy than those < 75 years. However, the 30-day mortality, 1- and 3-year survival rates for patients undergoing curative surgery were comparable.

COVID-19 recovery: tackling the 2-week wait colorectal pathway backlog by optimising CT colonography utilisation

AIM

To review the indications for computed tomography colonography (CTC) performed on patients referred via the 2-week wait colorectal pathway (2WWCP).

MATERIALS AND METHODS

A retrospective study was performed on all patients referred through the 2WWCP between October 2018 and September 2019. The referrals were audited against the National Institute for Health and Care Excellence (NICE) NG12/DG30 guidelines for referral to the 2WWCP, and against the Royal College of Radiologists (RCR) 2017 guidelines for CTC.

RESULTS

Over the study period, there were 1,707 2WWCP referrals, and 362 (21.2%) of these patients underwent CTC. The median age was 66 years, and 55% were female. Forty-six patients did not meet the NICE NG12/DG30 guidelines for referral to the 2WWCP, and a further 268, although meeting the NICE guidelines, did not meet the RCR 2017 guidelines for CTC. In total, only 13% of CTCs performed complied with both guidelines.

CONCLUSION

This audit demonstrated a significant opportunity to reallocate CTC resources in the recovery stage of the COVID-19 pandemic. To improve outcomes for colorectal cancer (CRC) in the UK, establishing a selective straight-to-test CTC 2WWCP should be considered. Documented consent detailing the risks and benefits of CTC versus colonoscopy should take place in order to assist the patient in making an informed choice.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

EFFECT OF NATIONAL PROGRAMS IN ONCOLOGY ON SURVIVAL OF PATIENTS WITH RECTAL CANCER: A POPULATION-BASED ANALYSIS

Objective. Assessment of the impact of National Program «Health» on a rectal cancer (RC) tumor-specific survival in the Arkhangelsk region (AR), Russia over the period 2000–2017 by the data of Arkhangelsk Regional Cancer Registry (ARCR)

Materials and methods. Anonymized data on all cases of RC (C19.0–C21.0) in the AR in 2000–2017 were extracted from the database of the ARCR. Over the study period, 4173 cases of the RC were selected. To assess the impact of the National Health Project in 2006 and All-national Dispensarization in 2013, the three time periods were chosen — 2000–2006, 2007–2012 and 2013–2017. Cancer-specific survival (CSS) was calculated. Separate influence of baseline factors on differences in CSS between periods was performed using Cox regression with consecutive input.

Results. One- and five year CSS were 62,6% (95% confidence interval (CI) 60,03–65,05%%) and 27,8% (95% CI 25,4–30,2%) in 2000–2006, 65,1% (95% CI 62,5–67,5%) and 32% (95% CI 29,5–34,5%) in 2007–2012, 67,7% (95% CI 65,2–70,1%) and 37,4% (95% CI 33,7–41,1%) in 2013–2017, respectively.

In univariate analysis the risk of death in the latest time periods was significantly lower: HR 0.86 (95% CI 0.79–0.95), p < 0.05 and 0.74 (95% CI 0.67–0.82), p<0.0001 for 2007–2012 and 2013–2017, respectively, comparing to 2000–2006. In a multivariate model only correction for treatment type has led to change of the coefficients between time periods: HR 0.94 (95% CI 0.86–1.03) and 0.84 (95% CI 0.75–0.93) for 2007–2012 and 2013–2017, respectively. The CSS was also in­dependently influenced by stage, age at diagnosis, place of residence and type of treatment.

Conclusion. Population-based five-year CSS of patients with RC increased by 8% during the analyzed period. Better CSS in the latest time period is associated rather with improvement of treatment than earlier detection of RC.

Surgical approach and geriatric evaluation for elderly patients with colorectal cancer

This review aims to define the most appropriate surgical approach and geriatric evaluation for elderly patients with colorectal cancer (CRC). Surgery represents the main treatment for CRC, but elderly cancer patients still represent a challenge for the surgeon due to frequent comorbidities such as cardiovascular and pulmonary diseases, which increase operative risk as well as the risk of postoperative morbidity and mortality. Cancer patients with comorbidities show lower survival rates and quality of life, together with higher healthcare costs. There is also evidence that patients with comorbidities sometimes receive modified treatment, compromising optimal care. To optimize treatment, the approach to elderly cancer patients needs a multidisciplinary team to assess preoperative conditions, prevent post-surgical complications and improve outcome, especially for frail patients. Laparoscopic surgery for CRC shows a number of advantages compared to conventional surgery such as less postoperative pain, rapid return to prior activities and a decrease in costs. Recent studies confirm that laparoscopic procedures could be performed safely on both older and younger patients with no difference compared with open surgery as regards morbidity or length of hospital stay.

Rates of Prevalent Colorectal Cancer Occurrence in Persons 75 Years of Age and Older: A Population-Based National Study

BACKGROUND/AIMS

There is a lack of studies describing the epidemiology of colorectal cancer (CRC) in patients aged 75 years and older (elderly). Current guidelines recommend against routine screening colonoscopies in this population. We sought to describe the epidemiology of CRC in the elderly, utilizing a large, population-based database as this may impact screening guidelines in this population.

METHODS

Utilizing a commercial database (Explorys Inc, Cleveland, OH), we identified a cohort of patients with a first-ever diagnosis of CRC between 2012 and 2017 based on the Systematized Nomenclature of Medicine-Clinical Terms. We calculated the rate of first-ever CRC occurrence in the elderly, described age, race, and gender-based rates of new CRC diagnoses, and identified associated conditions for new CRC in the elderly.

RESULTS

The rate of first-ever CRC in the elderly (aged 75 and above) was 102.6/100,000 persons. The rate of new CRC was higher in males than females and in African Americans than Caucasians and Asians. There was a higher prevalence of right than left colon cancer. The rate of new CRC was higher in elderly with certain comorbidities.

CONCLUSION

The rate of new CRC diagnosis in the elderly was substantially greater compared to the overall population. Screening would be justified especially if a patient's life expectancy warrants it particularly if the patient has specific associated conditions that increase the risk for CRC.