Colorectal cancer in geriatric patients: Endoscopic diagnosis and surgical treatment

Quality of life in Malaysian colorectal cancer patients

INTRODUCTION

The rapidly increasing of incidence colorectal cancer (CRC) in Malaysia and the introduction of new treatments that prolong survival advocating treatment outcome measures such as patients' quality of life (QOL) are evaluated in this study. The study aims to determine QOL in CRC patients according to cancer stage and age.

METHODS

A cross-sectional study was performed from June to December 2011 at four public tertiary hospitals. The European Organization for Research and Treatment in Cancer (EORTC) Quality of Life Questionnaire Core-30 (EORTC QLQ C-30) questionnaire was used through face-to-face interview and the medical records of 160 respondents were reviewed.

RESULTS

The mean age of respondents was 58.47 ± 12.04 years with 57.5% of respondents being male and 42.5% female. The majority of respondents were in CRC stages III and IV. Median global health status (GHS) score was 83.33 (IQR 16.67). Sikhs and Indians had a higher median GHS score compared to other ethnicities (Kruskal-Wallis, χ(2)  = 12.12, p = 0.007). Emotional, cognitive and social functions were higher in respondents with earlier stage of disease (Kruskal-Wallis, χ2 = 6.06, 6.36, 10.58, p = 0.048, 0.042, 0.005). Median pain, dyspnea, diarrhea and financial implication scores were significantly higher in advanced stage of disease (Kruskal-Wallis, χ(2)  = 9.31, 6.26,6.77, 7.28, p = 0.010, 0.044,0.034,0.026). Median diarrhea score (p = 0.012) was significantly different between age groups.

DISCUSSION

Emotional, cognitive and social functions deteriorate with advanced stage of disease. Patients with advanced stage disease experience more pain, dyspnea, diarrhea and financial implications. A systematic screening program to detect cases as early as possible is essential nationwide.

Is 30-day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

AIM

The study aimed to define mortality in the elderly following elective colorectal resection and to identify the most meaningful postoperative period to report mortality rates in this group of patients.

METHOD

A systematic review was undertaken to identify studies that reported on mortality in the elderly following elective colorectal resection. Searches of MEDLINE, Embase and PubMed databases were carried out by two independent reviewers and the results were collated. Two reviewers conducted literature searches independently and the third reviewer acted as an arbiter in case of discordance.

RESULTS

Two-hundred and thirty-six studies published in 2000 or later were identified in the search. Studies were excluded if they included emergency surgery, included patients receiving surgery before 1995, or did not comment on mortality in an elderly age group. Seventeen studies were finally included in the review. Thirty-day or postoperative mortality rates varied from 0 to 13.3%. Short-term mortality was low in elderly patients selected for minimal access surgery. National population and registry observational audits reported higher short-term mortality rates than most small case series or cohort studies. One national audit demonstrated that a significant mortality risk persists for up to 1 year after surgery.

CONCLUSION

Historical case series suggest that 30-day mortality following colorectal resection in the elderly is low. The reliability of 30-day mortality measures to reflect surgical success in this cohort is, however, questionable as a significant proportion of patients die in the months following surgery.

Optimizing the management of elderly colorectal surgery patients

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Comparison of CT colonography vs. conventional colonoscopy in mapping the segmental location of colon cancer before surgery

Once presence of a colorectal cancer has been diagnosed, a key factor for patient's prognosis in view of surgical intervention is the correct segmental localization and resection of the tumor. The aim of this work was to compare the accuracy of the current gold standard technique, conventional colonoscopy (CC), to computed tomography colonography (CTC) in the segmental localization of tumor. Sixty-five patients (mean age 64; 45 female and 19 male) with colorectal cancer diagnosed at colonoscopy underwent CTC before surgery. In 45 out of 65 cases (69%), patients were referred to CTC after incomplete CC. Reasons were patient intolerance to CC or presence of stenosing cancer, with consistent difficulties in crossing the tract of the colon involved by the lesion. CTC allowed the complete colonic examination in 63/65 cases, since in 2 patients with an obstructing lesion of the sigmoid colon, pneumocolon could not be obtained. However, per patient and per lesion sensitivity of CTC was 100%. Difference from colonoscopy was statistically significant (P < 0.05). In terms of segmental localization of masses, CTC located precisely all lesions, while colonoscopy failed in 16/67 (24%) lesions, though six were missed for incomplete colonoscopy (9%). In the remaining 10/67 (15%) lesions, detected by colonoscopy but incorrectly located, the mismatch occurred in the rectum (n = 3), sigmoid (n = 2), descending (n = 1), transverse (n = 2), ascending colon, and cecum. Agreement between CTC and CC was fair (k value 0.62). Sensitivity, specificity, positive predictive value and negative predictive value of CTC in determining the precise location of colonic masses were respectively 100%, 96%, 85%, and 100%. CT detected hepatic (6/65 patients) and lung metastases (3/65 patients). CT colonography has better performance in the identification of colonic masses (diameter > 3 cm), in the completion of colonic evaluation and in the segmental localization of tumor. CTC should replace colonoscopy for preoperative staging of colorectal cancer.

Colorectal surgery in octogenarian patients--outcomes and predictors of morbidity

INTRODUCTION

Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer.

METHODS

A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates.

RESULTS

The patients had a mean age of 83.5 years (range, 80-99). The mean index of comorbidity was 3.1 (2-7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification > or =3 and comorbidity index 3 of 5 > or = 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity.

CONCLUSION

Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.

Long-term follow-up and predictive factors of recurrence of anemia in a cohort of 102 very elderly patients explored for iron-deficiency anemia

AIM

To evaluate long-term follow-up and predictors of relapse of anemia in a cohort of 102 very elderly patients previously explored for iron-deficiency anemia (IDA).

METHODS

One hundred and two patients [61 women and 41 men, mean age 82+/-5.8 y (75 to 98)] explored for IDA were prospectively followed up from inclusion (June 2003 to May 2005) until death or May 2006. Survival rate was estimated by the Kaplan-Meier method and compared by the log-rank test. Predictors of recurrence of anemia were identified by multivariate analysis in the 4 following subgroups: unexplained IDA (subgroup 1, n=27), benign lesion (subgroup 2, n=37), cancer treated curatively (subgroup 3, n=28), cancers treated palliatively (subgroup 4, n=10).

RESULTS

Median follow-up was 20 months. At baseline, main clinical and laboratory data were not significantly different in the 4 subgroups, especially as regards severe comorbidities. Thirty-three patients died, 10 (30%) of them in the first month. Ten (100%) belonged to subgroup 4 versus, respectively, n=7 (26%), n=8 (22%), and n=8 (29%) of patients from subgroups 1, 2, and 3 (P<0.001). No death was directly related to recurrence of anemia. Survival rate at 1 year was 10% in subgroup 4, significantly lower than the other 3 subgroups (subgroup 1: 84%; subgroup 2: 86%; subgroup 3: 78%; log-rank test, P<0.0001). Anemia recurred in 18 cases, and required red cell transfusion in 13 cases. Predictive factors of recurrence of anemia [odds ratio (confidence interval 95%), P] were cancers treated palliatively [14.9 (3-72), P<0.01] and angiodysplasias [4.5 (1.1-18.2), 0.035].

CONCLUSIONS

In a cohort of very elderly patients explored for IDA, the mortality rate and the long-term survival were not different for patients with IDA related to a cancer treated curatively than those with unexplained IDA and those with IDA related to a benign lesion. Angiodysplasias and cancers treated palliatively were associated with recurrence of anemia. These results suggest interventionist strategies (including endoscopic investigation and appropriate surgery) for elderly patients with IDA.

FACTORS AFFECTING THE MORTALITY RISK IN ELDERLY PATIENTS UNDERGOING SURGERY

BACKGROUND

Factors affecting the mortality in elderly patients vary among different studies. This study investigates the influence of the patient-related factors, especially the effect of the diseased organ system on the mortality risk in the elderly.

METHODS

Records of 942 operated patients aged 70 years and over were retrospectively examined. Age, sex, site of the diseased organ system, type of admission, benign/malign nature, American Society for Anesthesiologists (ASA) score, main surgical diagnosis, method of surgical therapy and concomitant diseases were examined for their influence on the mortality.

RESULTS

There were 501 men and 441 women. Mean age was 75.5 years. Most of the patients had colorectal pathologies. Emergency surgery was carried out in 313 patients. Mortality rate was 11.8%. Cardiogenic shock was the leading cause of mortality. There was a strong linear correlation between ASA score and mortality. Logistic regression analysis concluded that higher (> or =3) ASA scores, operations under emergent conditions and diseases of the colorectal and upper gastrointestinal systems were significantly associated with higher mortality rates.

CONCLUSION

When combined with ASA score and type of admission, site of the diseased organ system may be a good indicator of mortality in the elderly patients undergoing surgery.

Management and predictors of early mortality in elderly patients with iron deficiency anemia: a prospective study of 111 patients

OBJECTIVES

Iron deficiency anemia (IDA) is common in the elderly. It usually results from gastrointestinal (GI) bleeding and requires endoscopic exploration of the gastrointestinal tract. The aim of this prospective study in elderly patients was to evaluate the feasibility of endoscopy, the therapeutic impact, and identify predictors of early mortality.

METHODS

From June 2003 to May 2005, all patients over 75 years, hospitalized for anemia were screened for iron deficiency. Clinical (including serious comorbidities), biological, endoscopic and therapeutic data were collected. One month after treatment, a follow-up was carried out to assess the tolerance of such investigation and treatment.

RESULTS

One hundred and eleven patients (69 women, 82.3 +/- 6.4 years) had IDA, 102 (92%) underwent an upper endoscopy and 91 (82%) a colonoscopy. Nine (8%) patients were not investigated because of poor clinical condition (N=4) or dementia (N=5). Of the 75 (68%) patients with an identified source of bleeding, 12 (11%) had a synchronous lesion, 43 (39%) a colorectal source including 31 (72%) colorectal cancer, and 44 (40%) an upper GI source. Sixty-nine (92%) of the 75 patients received at least one of the following treatments: medical (N=27), endoscopic (N=20), and surgical (N=31). Surgery was curative in 28/31 (90%) cases of which 25/27 were colorectal cancers. One month after treatment, overall mortality was 11/111 (10%) and 4/31 (13%) after surgery. Predictors of early mortality (Odd ratio, 95% Confidence Interval) were: a malign cause (42; 3-588), no specific treatment (34; 3-423), at least 2 co-morbidities (20; 1-400).

CONCLUSION

In an unselected hospitalized population of elderly patients with IDA, endoscopy was generally feasible, allowing identification of a source of bleeding, especially colorectal cancer. A specific treatment was usually possible and proved curative without increase in early mortality.