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Surgery in older patients
Surgery in Older Patients M. Margaret Kemeny Surgery for solid tumors is often withheld from the very elderly because of perceptions that they could not tolerate it physically and often because their life expectancy is considered too short. Data have shown that both of these factors should be carefully considered for the individual patient, since the mortality from most operations, even such major surgeries as liver resections, is no different for the fit elderly than for younger patients. One of the main problems is that the elderly are often not diagnosed and treated early enough to prevent emergency operations that carry a much higher mortality. Many new surgical techniques have made cancer surgery less invasive; this is especially true for stage I and II breast cancer. These advances have increased the potential for curative cancer surgeries that can be offered to all patients regardless of advanced age. Semin Oncol 31:175-184. © 2004 Elsevier Inc. All rights reserved.
S
URGERY REMAINS the most important treatment modality for patients with solid tumors regardless of age. Cancer surgery in the elderly is becoming an increasingly compelling topic because of the rise in the numbers of elderly people in the population of the United States. Not only are there more elderly people than ever before, but the incidence of cancer increases with age. Thus, the numbers of elderly patients requiring surgical intervention can be expected to rise markedly in the next decades. Because clinicians often underestimate the life expectancy of elderly patients, cancer is frequently undertreated. In fact, the life expectancy of a person reaching the age of 65 is an additional 17.5 years; and an additional 11 years for one reaching 75. An 85-year-old is likely to live an additional 6 years.1 All of these life expectancies are greater than the usual 5-year survival oncologists look for in treating patients with cancer. In other words, elder patients should get adequate initial therapy for cancer so they do not have recurrences, metastases, or death from a cancer that may have been prevented by correct treatment at the outset. The solid tumors most commonly seen by surgical oncologists in the elderly are colorectal, breast, gastric, and pancreatic cancer. All of these require surgery for cure. What constitutes “optimal” surgical therapy for the elderly is often uncertain because the elderly have been severely underrepresented in most clinical trials. Seminars in Oncology, Vol 31, No 2 (April), 2004: pp 175-184
Many factors should influence the selection of therapy in the elderly. Especially important are: perceived limited life expectancy; the presence of comorbid diseases, decreased functional status, alterations in mental status, and presumed inability to tolerate treatment. All of these factors should be taken into account to optimize therapy, but they should not be used to withhold appropriate treatment. Surgery in particular has often been viewed as carrying prohibitive risk for morbidity and mortality in the elderly patient. However, the literature has not supported this viewpoint and numerous studies have indicated that surgical procedures can be performed safely in the elderly.2-10 The balance between operative risk and expected cure or palliation is important when treating any patient with cancer but especially the elderly patient. The impact of treatment on quality of life is also of prime importance. Many potentially curative cancer operations are complex and extensive with significant morbidity and mortality. RISK ASSESSMENT
The determination of operative risk in the elderly is difficult and imprecise. Age alone should not be used as the sole criteria to assess risk or to make therapeutic decisions. The assessment of risk should involve factoring the underlying physiologic status, including the normal physiologic changes of aging, comorbid diseases, extent of the cancer, the surgical procedure itself, and the risks of anesthesia. With aging, normal physiologic changes occur in every major organ system and affect the outcome of surgical procedures.11 Operative risk can be assessed in several ways. One of the most common scales still used today to grade operative risk from anesthesia is the American Society of Anes-
From the Queens Cancer Center of Queens Hospital, Jamaica, NY; and the Mount Sinai School of Medicine, Jamaica, NY. Address reprint requests to M. Margaret Kemeny, MD, FACS, Queens Hospital Center, Mt. Sinai Svc, 82-88 16th St, Jamaica, NY 11432. © 2004 Elsevier Inc. All rights reserved. 0093-7754/04/3102-0006$30.00/0 doi:10.1053/j.seminoncol.2003.12.028 175
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Table 1. ASA Classification Class I: The patient has no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which the operation is to be performed is localized and does not entail a systemic disturbance. Class II: Mild to moderate systemic disturbances caused by the conditon to be surgically treated or the pathophysiologic processes. The extremes of age are included here, the neonate or the octogenarian, even though no discernible systemic disease is present. Extreme obesity and chronic bronchitis also are included in this category. Class III: Severe systemic disturbance or disease from whatever cause, even though it may not be possible to firmly define the degree of disability. Class IV: Indicative of the patient with severe systemic disorders that are already life-threatening and not always correctable by an operation. Class V: The moribund patient who has little chance of survival but who has submitted to operation in desperation. Most of these patients require an operation as a resuscitative measure with little, if any, anesthesia. Emergency Operation (E): Any patient in classes I through V who is operated on as an emergency is considered to be in poor physical condition. The letter E is placed beside the numerical classification.
thesiologists general classification of physical status.12 This scale demonstrates a relationship between the mortality rate related to anesthesia and the physical status of the patient defined according to five groups (Table 1). Other measures of specific organ system risk exist. Cardiac events remain a primary cause of perioperative morbidity and mortality. Nine factors were found to independently predict cardiac complications by multivariate analysis in patients undergoing noncardiac surgery.13,14 A discriminant-function coefficient was assigned to each factor and a point value derived (Table 2). Four risk categories were defined based on each patient’s point total. The categories correlated well with the risk for cardiac death (Table 3). Age over 70 does contribute to an increased risk for cardiac complications. These risk categories were not designed to be exclusionary, but to increase the awareness for potential complications and ensure full preoperative evaluation and attempt to provide interventions to decrease the risk of surgery. Invasive monitoring is much more frequently used during and after operations in most cancer
resections. Some studies have advocated that this type of monitoring may be especially useful to evaluate and optimize hemodynamic function for the elderly patient.15-17 Careful preoperative assessment of physiologic status and the severity of any coexisting diseases can be used to guide therapeutic interventions to optimize results before, during, or in the postoperative recovery period. Increases in surgical morbidity and mortality are associated with advanced disease states and in patients requiring emergency surgery. Moreover, there is often a delay in cancer diagnosis in elderly patients, leading to more advanced cancers and emergency presentations.5,8 Early diagnosis and treatment in the elderly should be encouraged. BREAST CANCER
Carcinoma of the breast is the most common cancer in American women, with more than 200,000 new cases of invasive breast cancer expected in 2003.18 Nearly one third of new breast cancers occur in women over the age of 70, and over half the deaths from breast cancer are in women older than 65.19,20 Surgery plays a major role in the treatment of breast cancer, both in elderly and younger patients. Surgery may be nec-
Table 2. Goldman Criteria for Predicting Postoperative Cardiac Complications Criteria 1. S3 gallop or jugular-vein distention on preoperative examination 2. Myocardial infarction in the preceding 6 months 3. Rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram 4. ⬎5 premature ventricular contractions/ min documented at any time before operation 5. Age ⬎70 years 6. Emergency operation 7. Important valvular aortic stenosis 8. Intraperitoneal, intrathoracic, or aortic operation 9. Poor general medical condition*
Point Value
11 10
7
7 5 4 3 3 3
* PO2 ⬍ 60 or PCO2 ⬎ 50 mm Hg, K ⬍ 3.0 or Cr ⬎ 3.0 mg/dL, abnormal SGOT, signs of chronic liver disease, or patient bed ridden from noncardiac causes.
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Table 3. Goldman Risk Catagories for Predicting Postoperative Cardiac Complications
Class
Point Total
No or Only Minor Complication
Life-Threatening Complication
Cardiac Death
I II III IV
0-5 6-12 13-25 ⱖ26
99% 93% 86% 22%
0.7% 5% 11% 22%
0.2% 2% 2% 56%
essary for diagnosis, for cure, or for palliation of symptoms. Whether surgical treatment of older patients should be different from that of younger patients with the same breast cancer stage remains unclear, partially because older patients have been previously excluded from many major randomized trials in the past. Retrospective studies are difficult to interpret because patients who underwent surgical intervention may have differed considerably from those who did not. Age bias may influence the selection of patients for surgery, both in clinical trials and in practice. Physicians may be concerned about comorbid illnesses, decreased functional status, changes in mental status, perceived limited life expectancy, and assumed inability to tolerate treatment, and they may feel that breast surgery in the elderly carries prohibitive risk. However, many studies have shown that such surgery can be performed safely in older patients.21-25 Breast surgery for all women has changed significantly over the last three decades. Surgery has progressed from all patients needing a radical mastectomy in the first part of the last century to the 21st century to the current practice of recommending lumpectomy and sentinel lymph node (SLN) biopsy for most patients. Mastectomies historically required a week of hospitalization; now almost all the breast surgery can be performed in the outpatient setting. Along with less invasive procedures comes the lowering of the risks, making current standard operative care for breast cancer an extremely low-risk event. Randomized controlled trials in the United States and Europe with 20 years of follow-up have shown that in early stage breast cancer, breastconserving therapy (BCT) followed by breast radiation is equivalent to mastectomy for overall survival.26,27 However, these data do not include many older women. It is now believed that BCT is the preferred method for treating early stage breast
cancer,28 and the use of BCT has increased in all ages. A review using the SEER (Surveillance, Epidemiology and End Results) database of over 100,000 women diagnosed with stage I or II breast cancer from 1983 to 1995 showed increasing use of BCT relative to mastectomy, especially from 1990 to 1995. In the older age groups, BCT increased among 70- to 79-year-old women from 19% in the period from 1983 to 1990 to 39.2% in 1990 to 1995, and from 23.1% to 34.7% during the same time periods among women ⱖ80 years old.21 These data do indicate, however, that the majority of older women still do not undergo BCT. Furthermore, they are less likely than younger women to have BCT. In the period from 1990 to 1995, women ages 70 to 79 were only 58% as likely to undergo BCT compared with those under age 50, and women ages ⱖ80 were only 50% as likely to have BCT as those under age 50.23 Older women undergoing BCT are more likely to have postoperative radiation therapy omitted. In the review of SEER data from 1990 to 1995, 82.4% women under 50 years of age had radiation after BCT, 80.2% of women ages 70 to 79 had radiation therapy, but only 48.5% of women ⱖ80 years had radiation.21 The odds ratios for women in the older groups receiving radiation compared with women under age 50 were 0.82 for women ages 70 to 79 but only 0.18 for those ⱖ80 years old. Reasons for the omission of breast radiation in older women are unclear. Concern about comorbidities may be one factor, though studies taking comorbidities into account have also found that radiation is often omitted in older patients. A trial specifically designed for women 70 and older was performed at the Cancer and Leukemia Group B, a National Cancer Institute-sponsored multi-institutional cancer cooperative group. In this trial, patients with T1 estrogen receptor-positive or progesterone receptor-positive breast can-
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cer were treated with lumpectomy and tamoxifen and were randomized to breast radiation or no radiation. The early results in this trial were presented in abstract form and showed no survival benefit for breast radiation.29 This study will have an impact on surgery because many surgeons erroneously believe that elderly women cannot tolerate 5 to 6 weeks of radiation therapy and recommend mastectomy. Limited data suggest breast radiation is well tolerated in older patients and older women treated with lumpectomy should be considered for breast radiation unless their predicted survival is very short. Breast-conserving therapy should be offered to older women; in a large survey performed by the American College of Surgeons Commission on Cancer there were no differences in stage at diagnosis among the elderly and younger patients and most patients presented with stage I or II breast cancer amenable to BCT.25 Most of the tumors in these elderly patients were also hormone receptorpositive.25 In one large series of over 10,000 women, 63% of those younger than 50 had estrogen receptor positive tumors versus 83% of those older than 50. 30 Recently, SLN biopsy has become the operation of choice for evaluating the axilla in women with stage I and II breast cancers. A randomized trial comparing SLN with axillary dissection is currently in progress (National Surgical Adjuvant Breast & Bowel Project trial NSABP B-32), but SLN is now considered appropriate therapy by many surgical oncologists. For older women it is particularly helpful because it means all surgery can be performed under local anesthesia in the outpatient setting. Before the technique of SLN biopsy, some surgeons did not feel axillary dissections were necessary in elderly women. In a series of 321 patients over 70 years old with clinically negative axillae treated with surgery and tamoxifen without node dissection, an axillary recurrence rate of only 4.3% was shown.31 In a smaller series, only one axillary recurrence was seen at 103 months after treating the axilla with radiation and no surgery.32 This dilemma of whether or not to perform axillary dissection has been obviated for most patients by the introduction of SLN biopsy. In an attempt to better define why older women receive less than definitive therapy for breast cancer, one study explored how age, marital status, health status, tumor characteristics, and aspects of
M. MARGARET KEMENY
physician-patient interaction influenced treatment.33 The following factors, along with the percentage of patients citing them, were found to be very important in their choice for therapy: minimizing possibility of recurrence, 100%; doctor’s recommendation, 96%; quality of life after treatment, 77%; their family’s opinion, 52%; the cost to the patient over and above insurance, 28%; problems they would experience after surgery, 22%. The following factors were found not to be important in the choice: effect of treatment on sexuality, 83%; difficulty getting to and from medical care facilities, 65%; effects of treatment on cosmesis, 63%. Patient age, marital status, and the number of times the breast cancer specialist discussed treatment options were independently and significantly associated with the receipt of definitive primary tumor therapy. Older women who were not married and women with whom treatment options were discussed less frequently were less likely to receive definitive primary therapy. The conclusion of the authors was that when older women have been diagnosed with breast cancer and there is clinical uncertainty as to the most appropriate treatment these patients are better served if they are offered choices from among definitive therapies. A second possible explanation for undertreatment in elderly patients is that physicians may equate advancing age with limited inherent life expectancy. Shortened life expectancy cannot and should not be used as an argument against appropriate breast cancer treatment in most elderly patients. Until well-performed studies show that it is safe to treat the elderly differently, breast cancer in the elderly should be approached with the same guidelines as for younger patients. COLORECTAL CANCER
Colorectal cancer ranks third in incidence in both men and women after lung, breast, and prostate cancer. Over 107,000 new cases of colon cancers and 41,000 new cases of rectal cancer were diagnosed in the United States in 2002.18 Moreover, in 1990, the National Cancer Data Base showed that 55.5% of colon cancer and 46.4% of rectal cancer occurred in individuals over the age of 70.34 Curative therapy for cancer of the colon and rectum almost always includes surgery. Palliative therapy with surgery is also often required, even in
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Table 4. Mortality of Surgical Resections for Colorectal Cancer
Study
Age (yr)
No. of Patients
Total Op Mortality (%)
Elective Op Mortality (%)
Emergency Op Mortality (%)
Colorectal Cancer Collaborative Group35
65-74 75-84 ⬎85
10,863 9,164 2,567
6.4 8.6 19.4
0* 1.0 2.0
— — —
Greenberg et al5
⬎70
163
10.4
7.5
23.3
al6
⬎75 65-75
8.2 5.8
8.2 5.8
— —
⬎80
—
4.7
41
Hesterberg et
Spivak et al36
* Studies that included only elective surgery.
the presence of disseminated disease, to avoid or treat the complications of obstruction and bleeding. Many recent studies, most retrospective, have evaluated the risk of surgical resection in patients with advanced age and colorectal cancer (Table 4). As expected with increasing age, the operative mortality increases, but not significantly in most studies. Furthermore morbidity and mortality in older patients is often related to more advanced disease, emergency operative conditions, and comorbidities. A large review of colorectal surgery in elderly patients from Britain was recently published.35 The authors analyzed data from over 34,000 patients, including over 10,000 between the ages of 65 and 74, over 9,000 between the ages of 75 and 84, and over 2,000 patients 85 and older. The median mortality rate for each group increased with age (3% for the youngest, 6.4% for the 65 to 74, 8.6% for the 75 to 84, and 19.4 for the over 85 age group). However, when studies of only elective surgery were examined, the mortality rates declined to 1.7%, 0%, 1.0%, and 2.0%, respectively. These data underscore the fact that many of the operations in older patients were performed as an emergency, raising the morbidity and mortality considerably. This study, like so many others, showed that cancer specific survival was similar among the elderly and younger patients; age alone should not be used to deny a patient curative surgery. Survival after curative resection for colon carcinoma has been reported in some studies to be lower for patients over 70 years of age.37 However, in one series, multivariate analysis showed that
3-year survival was influenced by disease stage and type of surgical procedure performed (resection v palliation), but not age (⬎80 v ⬍ 80 years of age).38 Hospital stay was longer for those over 80, as was the cost of treatment (22% increased cost). Another series indicated that while physical status and operative mortality were worse in the elderly undergoing surgery for colorectal cancer, for the elderly who are fit, who underwent curative resection, and who survived over 30 days, 5-year survival was similar to younger patients.39 In another series, cardiopulmonary complications after colorectal surgery were increased from 1.8% in patients under 65, to 10.8% in patients 65 to 75 and 8.2% in patients over 75 years of age.6 Anastomatic leak rates were also increased from 4.2% in patients under 65 to 8.2% in those over 75 years old.6 Mortality rates in this series were also higher; however, most series show that age is not an independent factor related to surgical risk. Older patients, especially those ⱖ80, are less likely to have tumors amenable to curative resection because older patients often present with more advanced-stage disease.40 Even palliative operations, such as creation of a colostomy, often carry high mortality rates because they are frequently performed as emergency procedures.5,36 With the increase in mortality associated with emergency surgery and advanced disease stage, it is crucial that older patients are diagnosed and treated as early as possible. The role for laparoscopy-assisted colon resection is presently being evaluated in patients with colon cancer. The advantages of laparoscopic co-
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lon resection may include a decrease in postoperative pain and ileus,41 a shorter hospital stay, and a faster return to normal lifestyle than with conventional colon resection. However, whether laparoscopic resection is as safe and effective as the standard resection procedure is uncertain and is being addressed in ongoing prospective randomized clinical trials. Of additional concern are documented laparoscopic port site recurrences after resections. Thirty-five recurrences were reported over a 2-year period in one recent review of the literature.42 Other potential options for palliative treatment and control of obstruction or hemorrhage in elderly patients with advanced rectal cancer are the use of local intraluminal therapies such as electrofulguration, laser therapy, or cryotherapy.43 Laser therapy is effective for palliation in 85% to 95% of patients, and procedure-related morbidity and mortality rates are low.43 Quality of life after colon resection has not been extensively explored in the elderly population. Creating a stoma must be viewed with caution because it may be difficult for some elderly patients to manage not only physically but psychologically. For patients with liver metastases from colorectal cancer, the use of liver resection for patients with one to three liver lesions is the optimal treatment for patients with liver-only metastases. Liver resections can be performed safely in elderly patients. A recent report compared patients with liver resections at a single institution using age as the discriminating criteria.4 For patients over 70 years of age, the perioperative mortality rate was similar to patients younger than 70. Morbidity rates were 42% and 40%, respectively, for the elderly and the younger group, with the majority of the complications in the elderly being cardiopulmonary in origin. After multivariate analysis, age was not found to be related to outcome. The median hospital stay for patients ⱖ70 was only 1 day longer than for patients less than 70 years old. Morbidity, mortality, intensive care unit admission rates, and long-term survival were not different between older patients and younger patients. While it was not clear what selection criteria were used to select these elderly patients for a major hepatic resection, it was clear that these procedures in the elderly were associated with a good operative survival and an equal likelihood of cure when compared with the younger patients.
M. MARGARET KEMENY
PANCREATIC CANCER
The incidence of pancreatic cancer increases with age. In one series, over two thirds of the patients were over the age of 65 at diagnosis.44 While the cure rate for pancreatic cancer is low, it can only be achieved with surgical intervention. However, most patients with pancreatic cancer present with late-stage disease and are unresectable.44 The percentage of patients with resectable cancers is even lower for patients after the age of 70. Even for patients who are able to undergo resection, mean survival is still only 10.6 to 24.6 months.45 Pancreaticoduodenectomy is the operation of choice for lesions in the head of the pancreas, periampullary area, duodenum, and distal common bile duct. These procedures were previously associated with a complication rate and mortality rate as high as 26%. When weighed against the relatively small survival benefit after a successful resection, many viewed the procedure as an unreasonable option for treatment,46,47 especially in elderly patients. However, recent series show that the morbidity and mortality rates associated with this operation have decreased significantly and now range between 0% and 5%.48,49 Even in the elderly, mortality rates for these extensive and complicated procedures are acceptable in selected patients.3,50,51 In a review of pancreatic cancer resection in 138 patients over the age of 70, the operative mortality rate of 6% and morbidity rate of 40% was seen, which are very acceptable outcomes for pancreatic resection.3 Univariate analysis showed that a history of cardiopulmonary disease, an abnormal preoperative electrocardiogram, and an abnormal chest radiograph were predictors of complications. However, in multivariate analysis, the only factor found to be a significant predictor of complications was a blood loss of more than 2 liters. No significant differences were found in length of hospital stay, rate of intensive care unit admission, or morbidity or mortality rates between patients younger than 70 and those older than 70. Median survival for all patients was 18 months, and the 5-year survival rate was 21%. Several smaller series of pancreatic resection have reported mortality rates in elderly patients in the range of 5% to 10%, with morbidity rates of 14% to 48%.52-54 In one series from Johns Hopkins
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Table 5. Gastric Resections in the Elderly Study Schwartz et
al*65
Bonenkamp et al66
Viste et al67
Age (yr)
No. of Patients
Morbidity
Mortality
⬎70
310
47.1%
7.1%
⬎70 D1 D2
231 128 103
30% 45%
7% 18%
ⱖ80
106
34%
15%
* 85% ⬎ D1 resections.
University, no operative mortality occurred after 37 consecutive pancreaticoduodenectomies in patients over the age of 70.48 Also, no significant differences were found between the length of stay or rate of complications in patients over 70 compared with younger patients. However, the patients in this series were carefully selected and had no differences in preoperative medical risk factors when compared with younger patients. Five-year survival rates after pancreatic resection are similar in older and younger patients. One series reported a 5-year survival rate for pancreatic cancer of 17% in patients over 70 and 19% in patients less than 70 years of age.51 Periampullary tumor survival rates were better for both groups at 38% and 45%, respectively. The majority of patients with pancreatic cancer are unresectable, but many need palliation for biliary and gastric obstruction.45 The elderly patient may not tolerate bypass procedures as well a younger patient. One Veteran’s Administration study showed a significantly higher 30-day morbidity and mortality rate and lower median survival rate after bypass procedures for patients over 70.55 For all patients, the risks and benefits of bypass surgery should be individualized. The operative mortality rate for biliary bypass ranges from 4% to 33% (mean, 19%) and overall survival from 1.5 to 12 months (mean, 5.4 months).56 Several randomized series have shown biliary obstruction can often be as effectively managed as bypass, with stents placed either endoscopically or percutaneously transhepatically.57-59 Mortality rates are lower for stent placement than for surgical bypass and hospital stays are shorter. While early complication rates are lower after stent placement, long-term complication rates
such as recurrent jaundice and cholangitis are more common than with surgical bypass. Gastric outlet obstruction, although far less common as a presenting symptom, still requires operative bypass for relief. Survival after gastric bypass is often short and furthermore, gastric bypass does not always result in palliation.60 Recently, the introduction of laparoscopic techniques has provided a new method of performing gastric bypass with the potential of lowering morbidity and mortality, especially in debilitated patients. GASTRIC CANCER
In the United States, gastric cancer, like pancreatic cancer, is usually a disease of the older person, with 50% of males and 60% of females over the age of 70.61 Curative treatment requires surgical removal of the cancer. Surgical treatment is often necessary for palliation of bleeding or obstruction. Information from several Japanese series of the characteristics of gastric cancer in the elderly show no difference in symptoms at presentation or the location of disease in the stomach between younger and older patients.62,63 The incidence of vascular and lymphatic invasion has been reported to be higher in the elderly, while there is no difference in the incidence of lymph node metastases and stage at diagnosis.63,64 The exact technique for curative surgery remains controversial as to the extent of surgery. The gastric resection itself is standard, but the extent of lymphadenectomy required varies. Removal of perigastric nodes (a D1 resection) should always be performed, while removal of more extensive regional lymph nodes outside the perigas-
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M. MARGARET KEMENY
tric region, termed “D2 resection,” is under scrutiny. Morbidity and mortality rates after gastric resections appear to be increased in the elderly compared with younger patients (Table 5). While preoperative risk factors are increased in the elderly, particularly cardiac and pulmonary disease, the majority of complications and deaths are caused by infection, anastomotic leak, and pulmonary problems, and are similar to those seen in younger patients.2,66-68 An important element in deciding about surgical treatment in the elderly is the impact of surgery on quality of life. One series from Japan assessed the quality of life after gastrectomy for gastric cancer in patients over 70 years of age compared with those younger than 70.69 After surgery no significant difference was found in the amount of food intake or weight change among older and younger patients. However, a significant decrease in performance status was found. Although performance status decreased after surgery in both groups, it improved in the younger patients, but remained decreased and unchanged in older patients. However, most older patients were still capable of self-care. The “health rate” and employment rate were lower after surgery for the elderly, but over half of those older patients who did not return to work felt it was not necessary for them to return rather than not possible for physical reasons. The authors concluded that the elderly should not be excluded from surgery based on quality-of-life concerns. In another smaller series of patients over 70 undergoing total gastrectomy, 70% of patients returned to “normal life” after 1 year, although the regaining of body weight was slower than in younger patients.70 Overall, the 5-year survival for curatively resected patients with gastric cancer is similar for younger and older patients.62,64 CONCLUSION
The incidence of most cancers increases with age. Breast, colorectal, gastric, and pancreatic cancers are the most common solid tumors seen by surgical oncologists in the United States, and all require surgical intervention for cure. Although the risk for surgery increases in the elderly with comorbidities, risk can be adequately evaluated to allow interventions that might potentially decrease morbidity and mortality. Appropriate surgical treatments must be offered to the elderly in a
timely fashion. Until there are studies that show the elderly can safely be managed in a different manner than younger patients, they should be offered standard treatment. A person’s age alone should not be used as a reason to deny them life-saving treatments. REFERENCES 1. Record high life expectancy. Statistical Bulletin, Metropolitan Insurance Companies, Jul-Sep 1993, pp 28-35 2. Bittner R, Schirrow H, Butters M, et al: Total gastrectomy, A 15-year experience with particular reference to the patient over 70 years of age. Arch Surg 120:1120-1125, 1985 3. Fong Y, Blumgart LH, Fortner JG, et al: Pancreatic or liver resection for malignancy is safe and effective for the elderly. Ann Surg 222:426-437, 1995 4. Fong Y, Cohen AM, Fortner JG, et al: Liver resection for colorectal metastases. J Clin Oncol 15:938-946, 1997 5. Greenburg AG, Saik RP, Pridham D: Influence of age on mortality of colon surgery. Am J Surg 150:65-70, 1985 6. Hesterberg R, Schmidt WU, Ohmann C, et al: Risk of elective surgery of colorectal carcinoma in the elderly. Dig Surg 8:22-27, 1991 7. Kojima Y, Yasukawa H, Katayama K, et al: Postoperative complications and survival after pancreato-duodenectomy in patients aged over 70 years. Surg Today 22:401-404, 1992 8. Morel P, Egeli RA, Wachtl S, et al: Results of operative treatment of gastrointestinal tract tumors in patients over 80 years of age. Arch Surg 124:662-664, 1989 9. Palmberg S, Hirsjarvi E: Mortality in geriatric surgery, with special reference to the type of surgery, anaesthesia, complicating diseases, and prophylaxis of thrombosis. Gerontology 25:103-112, 1979 10. Reiss R, Deutsch AA, Nudelman I: Abdominal surgery in elderly patients: Statistical analysis of clinical factors prognostic of mortality in 1,000 cases. Mt Sinai J Med 54:135-140, 1987 11. Evers BM, Townsend CM, Thompson JC: Organ physiology of aging. Surg Clin North Am 74:23-39, 1994 12. Dripps RD, Lamont A, Eckenhoff JE: The role of anesthesia in surgical mortality. JAMA 178:261-266, 1961 13. Goldman L: Cardiac risks and complications of noncardiac surgery. Ann Intern Med 98:504-513, 1983 14. Goldman L, Caldera DL, Nussbaum SR, et al: Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297:845-850, 1977 15. Buxbaum JL, Schwartz AJ: Perianesthetic considerations for the elderly patient. Surg Clin North Am 74:41-58, 1994 16. DelGuercio LR, Cohn JD: Monitoring operative risk in the elderly. JAMA 243:1350-1355, 1980 17. Pulmonary Artery Consensus Conference Participants: Pulmonary artery catheter consensus conference: Consensus statement. New Horizons 5:175-193, 1997 18. Jemal A, Thomas A, Taylor M, et al: Cancer statistics 2002. CA Cancer J Clin 52:23-47, 2002 19. Osteen RT, Karnell LH: Breast cancer, in Steele GD, Winchester DP, Menck HR, et al (eds): National Cancer Data Base. Annual Review of Patient Care 1993. Atlanta, GA, American Cancer Society, 1993
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20. Yancik R, Ries LA: Cancer in older persons. Magnitude of the problem-how do we apply what we know? Cancer 74: 1995-2003, 1994 21. Lazovich D, Solomon CC, Thomas DB, et al: Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference of the treatment of patients with early stage invasive breast carcinoma. Cancer 86:628-637, 1999 22. Yancik R, Ries LG, Yates JW: Breast cancer in aging women: A population-based study of contrasts in stage, surgery, and survival. Cancer 63:976-981, 1989 23. Singletary SE, Shallenberger R, Guinee VF: Breast cancer in the elderly. Ann Surg 218:667-671, 1993 24. Mandelblatt JS, Kerner JF, Hadley J, et al: Variations in breast carcinoma treatment in older Medicare beneficiaries. Cancer 95:1401-1414, 2002 25. Busch E, Kemeny M, Fremgen A, et al: Patterns of breast care in the elderly. Cancer 78:101-111, 1996 26. Veronesi U, Cascinelli N, Mariani L, et al: Twenty year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347:1227-1232, 2002 27. Fisher B, Anderson S, Bryant J, et al: Twenty year follow-up of a trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347:1233-1241, 2002 28. National Institute of Health Consensus Conference: Treatment of early-stage breast cancer. JAMA 265:391-395, 1991 29. Hughes KS, Schnaper L, Berry D, et al: Comparison of lumpectomy plus tamoxifen with and without radiotherapy in women 70 years of age or older who have clinical stage I, estrogen receptor positive breast carcinoma. Proc Am Soc Clin Oncol 20:93, 2001 (abstr) 30. Pujol P, Hilsenbeck SG, Chamness GC, et al: Rising levels of estrogen receptor in breast cancer over 2 decades. Cancer 74:1601-1606, 1994 31. Martelli G, DePalo G, Rossi N, et al: Long-term follow-up of elderly patients with operable breast cancer treated with surgery without axillary dissection plus adjuvant tamoxifen. Br J Cancer 72:1251-1255, 1995 32. Wazur DE, Erban JK, Robert NJ, et al: Breast conservation in elderly women for clinically negative axillary lymph nodes without axillary dissection. Cancer 74:878-883, 1994 33. Silliman RA, Troyan SL, Guadagnoli E, et al: The impact of age, marital status and physician-patient interactions on the care of older women with breast carcinoma. Cancer 80:1326-1334, 1997 34. Steele GP: Colorectal cancer, in Steele GD, Winchester DP, Menck HR, et al (eds): National Cancer Data Base: Annual Review of Patient Care 1993. Atlanta, GA, American Cancer Society, 1993, pp 20-36 35. Colorectal Cancer Collaborative Group: Surgery for colorectal cancer in elderly patients: A systematic review. Lancet 356:968-974, 2000 36. Spivak H, Maele DV, Friedman I, et al: Colorectal surgery in octogenarians. J Am Coll Surg 183:46-50, 1996 37. Gardner B, Dotan J, Shaikh, et al: The influence of age upon the survival of adult patients with carcinoma of the colon. Surg Gynecol Obstet 153:366-368, 1981
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38. Hobler KE: Colon surgery for cancer in the very elderly: Cost and 3-year survival. Ann Surg 203:129-131, 1986 39. Kingston RD, Jeacock J, Walsh S, et al: The outcome of surgery for colorectal cancer in the elderly: A 12-year review from the Trafford Database. Eur J Surg Oncol 21:514-516, 1995 40. Kemppainen M, Raiha I, Rajala T, et al: Characteristics of colorectal cancer in elderly patients. Gerontology 39:222227, 1993 41. Huscher C, Silecchia G, Croce E, et al: Laparoscopic colorectal resection. Surg Endosc 10:875-879, 1996 42. Johnstone PAS, Rohde DC, Swartz SE, et al: Port site recurrences after laparoscopic and thoracoscopic procedures in malignancy. J Clin Oncol 14:1950-1956, 1996 43. Dohmoto M, Hunerbein M, Schlag PM: Palliative endoscopic therapy of rectal cancer. Eur J Cancer 32A:25-29, 1996 44. Niederhuber JE, Brennan MF, Menck HR: The national cancer data base report on pancreatic cancer. Cancer 76:16711677, 1995 45. Watanapa P, Williamson RCN: Surgical palliation for pancreatic cancer: Developments during the past two decades. Br J Surg 79:8-20, 1992 46. Connolly MM, Dawson PJ, Michelassi F, et al: Survival in 1001 patients with carcinoma of the pancreas. Ann Surg 206:366-373, 1987 47. Edis AJ, Kiernan PD, Taylor WF: Attempted curative resection of ductal carcinoma of the pancreas. Review of Mayo Clinic experience, 1951-1975. Mayo Clin Proc 55:531-536, 1980 48. Cameron JL, Pitt HA, Yeo CJ, et al: One hundred and forty-five consecutive pancreaticoduodenectomies without mortality. Ann Surg 217:430-438, 1993 49. Michelassi F, Erroi F, Dawson PJ, et al: Experience with 647 consecutive tumors of the duodenum, ampulla, head of the pancreas, and distal common bile duct. Ann Surg 210:544-556, 1989 50. Hannoun L, Christophe M, Ribeiro J, et al: A report of forty-four instances of pancreaticoduodenal resection in patients more than seventy years of age. Surg Gynecol Obstet 177:556-560, 1993 51. Delcore R, Thomas JH, Hermreck AS: Pancreaticoduodenectomy for malignant pancreatic and periampullary neoplasms in elderly patients. Am J Surg 162:532-536, 1991 52. Spencer MP, Sarr MG, Nagorney DM: Radical pancreatectomy for pancreatic cancer in the elderly. Ann Surg 212: 140-143, 1990 53. Kairaluoma MI, Kiviniemi H, Stahlberg M: Pancreatic resection for carcinoma of the pancreas and the periampullary region in patients over 70 years of age. Br J Surg 74:116-118, 1987 54. Wade TP, Radford DM, Virgo KS, et al: Complications and outcomes in the treatment of pancreatic adenocarcinoma in the United States veteran. J Am Coll Surg 179:38-48, 1994 55. Sarr MG, Cameron JL: Surgical management of unresectable carcinoma of the pancreas. Surgery 91:123-133, 1982 56. Bornman PC, Tobias R, Harries-Jones EP, et al: Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery from incurable carcinoma of head of pancreas. Lancet 11:69-71, 1986
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57. Shepherd HA, Royle G, Ross APR, et al: Endoscopic biliary endoprosthesis in the palliation of malignant obstruction of the distil common bile duct: A randomized trial. Br J Surg 75:1166-1168, 1988 58. Andersen JR, Sorensen SM, Kruse A, et al: Randomised trial of endoscopic endoprosthesis versus operative bypass in malignant obstructive jaundice. Gut 30:1132-1135, 1989 59. Dowsett JF, Russell RCG, Hatfield ARW, et al: Malignant obstructive jaundice: A prospective randomized trial of by-pass surgery versus endoscopic stenting. Gastroenterology 96:A128, 1989 (abstr) 60. Weaver DW, Wienck RG, Bouwman DL, et al: Gastrojejunostomy: Is it helpful for patients with pancreatic cancer? Surgery 102:608-613, 1987 61. Wanebo HJ, Kennedy BJ, Chmiel J, et al: Cancer of the stomach. A patient care study by the American College of Surgeons. Ann Surg 218:583-592, 1993 62. Kitamura K, Yamaguchi T, Taniguchi H, et al: Clinicopathological characteristics of gastric cancer in the elderly. Br J Cancer 73:798-802, 1996 63. Bandoh T, Isoyama T, Toyoshima H: Total gastrectomy for gastric cancer in the elderly. Surgery 109:136-142, 1991 64. Maehara Y, Emi Y, Tomisaki S, et al: Age-related char-
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acteristics of gastric carcinoma in young and elderly patients. Cancer 77:1174-1180, 1996 65. Schwartz RE, Karpeh MS, Brennan MF: Factors predicting hospitalization after operative treatment for gastric carcinoma in patients older than 70 years. J Am Coll Surg 184:9-15, 1997 66. Bonenkamp JJ, Songun I, Hermans J, et al: Randomised comparison of morbidity after D1 and D2 dissection for gastric cancer in 996 Dutch patients. Lancet 345:745-748, 1995 67. Viste A, Haugstvedt T, Eide GE, et al: and The Norwegian Stomach Cancer Trial Members: Postoperative complications and mortality after surgery for gastric cancer. Ann Surg 207:7-13, 1988 68. Pacelli F, Bellantone R, Doglietto GB, et al: Risk factors in relation to postoperative complications and mortality after total gastrectomy in aged patients. Am J Surg 57:341-345, 1991 69. Habu H, Saito N, Sato Y, et al: Quality of postoperative life in gastric cancer patients seventy years of age and over. Int Surg 73:82-86, 1988 70. Koga S, Oda M, Kaibara N, et al: Total gastrectomy in the aged with special reference to postoperative convalescence and return to normal life. Dig Surg 2:31-35, 1985
S
URGERY REMAINS the most important treatment modality for patients with solid tumors regardless of age. Cancer surgery in the elderly is becoming an increasingly compelling topic because of the rise in the numbers of elderly people in the population of the United States. Not only are there more elderly people than ever before, but the incidence of cancer increases with age. Thus, the numbers of elderly patients requiring surgical intervention can be expected to rise markedly in the next decades. Because clinicians often underestimate the life expectancy of elderly patients, cancer is frequently undertreated. In fact, the life expectancy of a person reaching the age of 65 is an additional 17.5 years; and an additional 11 years for one reaching 75. An 85-year-old is likely to live an additional 6 years.1 All of these life expectancies are greater than the usual 5-year survival oncologists look for in treating patients with cancer. In other words, elder patients should get adequate initial therapy for cancer so they do not have recurrences, metastases, or death from a cancer that may have been prevented by correct treatment at the outset. The solid tumors most commonly seen by surgical oncologists in the elderly are colorectal, breast, gastric, and pancreatic cancer. All of these require surgery for cure. What constitutes “optimal” surgical therapy for the elderly is often uncertain because the elderly have been severely underrepresented in most clinical trials. Seminars in Oncology, Vol 31, No 2 (April), 2004: pp 175-184
Many factors should influence the selection of therapy in the elderly. Especially important are: perceived limited life expectancy; the presence of comorbid diseases, decreased functional status, alterations in mental status, and presumed inability to tolerate treatment. All of these factors should be taken into account to optimize therapy, but they should not be used to withhold appropriate treatment. Surgery in particular has often been viewed as carrying prohibitive risk for morbidity and mortality in the elderly patient. However, the literature has not supported this viewpoint and numerous studies have indicated that surgical procedures can be performed safely in the elderly.2-10 The balance between operative risk and expected cure or palliation is important when treating any patient with cancer but especially the elderly patient. The impact of treatment on quality of life is also of prime importance. Many potentially curative cancer operations are complex and extensive with significant morbidity and mortality. RISK ASSESSMENT
The determination of operative risk in the elderly is difficult and imprecise. Age alone should not be used as the sole criteria to assess risk or to make therapeutic decisions. The assessment of risk should involve factoring the underlying physiologic status, including the normal physiologic changes of aging, comorbid diseases, extent of the cancer, the surgical procedure itself, and the risks of anesthesia. With aging, normal physiologic changes occur in every major organ system and affect the outcome of surgical procedures.11 Operative risk can be assessed in several ways. One of the most common scales still used today to grade operative risk from anesthesia is the American Society of Anes-
From the Queens Cancer Center of Queens Hospital, Jamaica, NY; and the Mount Sinai School of Medicine, Jamaica, NY. Address reprint requests to M. Margaret Kemeny, MD, FACS, Queens Hospital Center, Mt. Sinai Svc, 82-88 16th St, Jamaica, NY 11432. © 2004 Elsevier Inc. All rights reserved. 0093-7754/04/3102-0006$30.00/0 doi:10.1053/j.seminoncol.2003.12.028 175
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Table 1. ASA Classification Class I: The patient has no organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which the operation is to be performed is localized and does not entail a systemic disturbance. Class II: Mild to moderate systemic disturbances caused by the conditon to be surgically treated or the pathophysiologic processes. The extremes of age are included here, the neonate or the octogenarian, even though no discernible systemic disease is present. Extreme obesity and chronic bronchitis also are included in this category. Class III: Severe systemic disturbance or disease from whatever cause, even though it may not be possible to firmly define the degree of disability. Class IV: Indicative of the patient with severe systemic disorders that are already life-threatening and not always correctable by an operation. Class V: The moribund patient who has little chance of survival but who has submitted to operation in desperation. Most of these patients require an operation as a resuscitative measure with little, if any, anesthesia. Emergency Operation (E): Any patient in classes I through V who is operated on as an emergency is considered to be in poor physical condition. The letter E is placed beside the numerical classification.
thesiologists general classification of physical status.12 This scale demonstrates a relationship between the mortality rate related to anesthesia and the physical status of the patient defined according to five groups (Table 1). Other measures of specific organ system risk exist. Cardiac events remain a primary cause of perioperative morbidity and mortality. Nine factors were found to independently predict cardiac complications by multivariate analysis in patients undergoing noncardiac surgery.13,14 A discriminant-function coefficient was assigned to each factor and a point value derived (Table 2). Four risk categories were defined based on each patient’s point total. The categories correlated well with the risk for cardiac death (Table 3). Age over 70 does contribute to an increased risk for cardiac complications. These risk categories were not designed to be exclusionary, but to increase the awareness for potential complications and ensure full preoperative evaluation and attempt to provide interventions to decrease the risk of surgery. Invasive monitoring is much more frequently used during and after operations in most cancer
resections. Some studies have advocated that this type of monitoring may be especially useful to evaluate and optimize hemodynamic function for the elderly patient.15-17 Careful preoperative assessment of physiologic status and the severity of any coexisting diseases can be used to guide therapeutic interventions to optimize results before, during, or in the postoperative recovery period. Increases in surgical morbidity and mortality are associated with advanced disease states and in patients requiring emergency surgery. Moreover, there is often a delay in cancer diagnosis in elderly patients, leading to more advanced cancers and emergency presentations.5,8 Early diagnosis and treatment in the elderly should be encouraged. BREAST CANCER
Carcinoma of the breast is the most common cancer in American women, with more than 200,000 new cases of invasive breast cancer expected in 2003.18 Nearly one third of new breast cancers occur in women over the age of 70, and over half the deaths from breast cancer are in women older than 65.19,20 Surgery plays a major role in the treatment of breast cancer, both in elderly and younger patients. Surgery may be nec-
Table 2. Goldman Criteria for Predicting Postoperative Cardiac Complications Criteria 1. S3 gallop or jugular-vein distention on preoperative examination 2. Myocardial infarction in the preceding 6 months 3. Rhythm other than sinus, or premature atrial contractions on preoperative electrocardiogram 4. ⬎5 premature ventricular contractions/ min documented at any time before operation 5. Age ⬎70 years 6. Emergency operation 7. Important valvular aortic stenosis 8. Intraperitoneal, intrathoracic, or aortic operation 9. Poor general medical condition*
Point Value
11 10
7
7 5 4 3 3 3
* PO2 ⬍ 60 or PCO2 ⬎ 50 mm Hg, K ⬍ 3.0 or Cr ⬎ 3.0 mg/dL, abnormal SGOT, signs of chronic liver disease, or patient bed ridden from noncardiac causes.
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Table 3. Goldman Risk Catagories for Predicting Postoperative Cardiac Complications
Class
Point Total
No or Only Minor Complication
Life-Threatening Complication
Cardiac Death
I II III IV
0-5 6-12 13-25 ⱖ26
99% 93% 86% 22%
0.7% 5% 11% 22%
0.2% 2% 2% 56%
essary for diagnosis, for cure, or for palliation of symptoms. Whether surgical treatment of older patients should be different from that of younger patients with the same breast cancer stage remains unclear, partially because older patients have been previously excluded from many major randomized trials in the past. Retrospective studies are difficult to interpret because patients who underwent surgical intervention may have differed considerably from those who did not. Age bias may influence the selection of patients for surgery, both in clinical trials and in practice. Physicians may be concerned about comorbid illnesses, decreased functional status, changes in mental status, perceived limited life expectancy, and assumed inability to tolerate treatment, and they may feel that breast surgery in the elderly carries prohibitive risk. However, many studies have shown that such surgery can be performed safely in older patients.21-25 Breast surgery for all women has changed significantly over the last three decades. Surgery has progressed from all patients needing a radical mastectomy in the first part of the last century to the 21st century to the current practice of recommending lumpectomy and sentinel lymph node (SLN) biopsy for most patients. Mastectomies historically required a week of hospitalization; now almost all the breast surgery can be performed in the outpatient setting. Along with less invasive procedures comes the lowering of the risks, making current standard operative care for breast cancer an extremely low-risk event. Randomized controlled trials in the United States and Europe with 20 years of follow-up have shown that in early stage breast cancer, breastconserving therapy (BCT) followed by breast radiation is equivalent to mastectomy for overall survival.26,27 However, these data do not include many older women. It is now believed that BCT is the preferred method for treating early stage breast
cancer,28 and the use of BCT has increased in all ages. A review using the SEER (Surveillance, Epidemiology and End Results) database of over 100,000 women diagnosed with stage I or II breast cancer from 1983 to 1995 showed increasing use of BCT relative to mastectomy, especially from 1990 to 1995. In the older age groups, BCT increased among 70- to 79-year-old women from 19% in the period from 1983 to 1990 to 39.2% in 1990 to 1995, and from 23.1% to 34.7% during the same time periods among women ⱖ80 years old.21 These data do indicate, however, that the majority of older women still do not undergo BCT. Furthermore, they are less likely than younger women to have BCT. In the period from 1990 to 1995, women ages 70 to 79 were only 58% as likely to undergo BCT compared with those under age 50, and women ages ⱖ80 were only 50% as likely to have BCT as those under age 50.23 Older women undergoing BCT are more likely to have postoperative radiation therapy omitted. In the review of SEER data from 1990 to 1995, 82.4% women under 50 years of age had radiation after BCT, 80.2% of women ages 70 to 79 had radiation therapy, but only 48.5% of women ⱖ80 years had radiation.21 The odds ratios for women in the older groups receiving radiation compared with women under age 50 were 0.82 for women ages 70 to 79 but only 0.18 for those ⱖ80 years old. Reasons for the omission of breast radiation in older women are unclear. Concern about comorbidities may be one factor, though studies taking comorbidities into account have also found that radiation is often omitted in older patients. A trial specifically designed for women 70 and older was performed at the Cancer and Leukemia Group B, a National Cancer Institute-sponsored multi-institutional cancer cooperative group. In this trial, patients with T1 estrogen receptor-positive or progesterone receptor-positive breast can-
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cer were treated with lumpectomy and tamoxifen and were randomized to breast radiation or no radiation. The early results in this trial were presented in abstract form and showed no survival benefit for breast radiation.29 This study will have an impact on surgery because many surgeons erroneously believe that elderly women cannot tolerate 5 to 6 weeks of radiation therapy and recommend mastectomy. Limited data suggest breast radiation is well tolerated in older patients and older women treated with lumpectomy should be considered for breast radiation unless their predicted survival is very short. Breast-conserving therapy should be offered to older women; in a large survey performed by the American College of Surgeons Commission on Cancer there were no differences in stage at diagnosis among the elderly and younger patients and most patients presented with stage I or II breast cancer amenable to BCT.25 Most of the tumors in these elderly patients were also hormone receptorpositive.25 In one large series of over 10,000 women, 63% of those younger than 50 had estrogen receptor positive tumors versus 83% of those older than 50. 30 Recently, SLN biopsy has become the operation of choice for evaluating the axilla in women with stage I and II breast cancers. A randomized trial comparing SLN with axillary dissection is currently in progress (National Surgical Adjuvant Breast & Bowel Project trial NSABP B-32), but SLN is now considered appropriate therapy by many surgical oncologists. For older women it is particularly helpful because it means all surgery can be performed under local anesthesia in the outpatient setting. Before the technique of SLN biopsy, some surgeons did not feel axillary dissections were necessary in elderly women. In a series of 321 patients over 70 years old with clinically negative axillae treated with surgery and tamoxifen without node dissection, an axillary recurrence rate of only 4.3% was shown.31 In a smaller series, only one axillary recurrence was seen at 103 months after treating the axilla with radiation and no surgery.32 This dilemma of whether or not to perform axillary dissection has been obviated for most patients by the introduction of SLN biopsy. In an attempt to better define why older women receive less than definitive therapy for breast cancer, one study explored how age, marital status, health status, tumor characteristics, and aspects of
M. MARGARET KEMENY
physician-patient interaction influenced treatment.33 The following factors, along with the percentage of patients citing them, were found to be very important in their choice for therapy: minimizing possibility of recurrence, 100%; doctor’s recommendation, 96%; quality of life after treatment, 77%; their family’s opinion, 52%; the cost to the patient over and above insurance, 28%; problems they would experience after surgery, 22%. The following factors were found not to be important in the choice: effect of treatment on sexuality, 83%; difficulty getting to and from medical care facilities, 65%; effects of treatment on cosmesis, 63%. Patient age, marital status, and the number of times the breast cancer specialist discussed treatment options were independently and significantly associated with the receipt of definitive primary tumor therapy. Older women who were not married and women with whom treatment options were discussed less frequently were less likely to receive definitive primary therapy. The conclusion of the authors was that when older women have been diagnosed with breast cancer and there is clinical uncertainty as to the most appropriate treatment these patients are better served if they are offered choices from among definitive therapies. A second possible explanation for undertreatment in elderly patients is that physicians may equate advancing age with limited inherent life expectancy. Shortened life expectancy cannot and should not be used as an argument against appropriate breast cancer treatment in most elderly patients. Until well-performed studies show that it is safe to treat the elderly differently, breast cancer in the elderly should be approached with the same guidelines as for younger patients. COLORECTAL CANCER
Colorectal cancer ranks third in incidence in both men and women after lung, breast, and prostate cancer. Over 107,000 new cases of colon cancers and 41,000 new cases of rectal cancer were diagnosed in the United States in 2002.18 Moreover, in 1990, the National Cancer Data Base showed that 55.5% of colon cancer and 46.4% of rectal cancer occurred in individuals over the age of 70.34 Curative therapy for cancer of the colon and rectum almost always includes surgery. Palliative therapy with surgery is also often required, even in
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Table 4. Mortality of Surgical Resections for Colorectal Cancer
Study
Age (yr)
No. of Patients
Total Op Mortality (%)
Elective Op Mortality (%)
Emergency Op Mortality (%)
Colorectal Cancer Collaborative Group35
65-74 75-84 ⬎85
10,863 9,164 2,567
6.4 8.6 19.4
0* 1.0 2.0
— — —
Greenberg et al5
⬎70
163
10.4
7.5
23.3
al6
⬎75 65-75
8.2 5.8
8.2 5.8
— —
⬎80
—
4.7
41
Hesterberg et
Spivak et al36
* Studies that included only elective surgery.
the presence of disseminated disease, to avoid or treat the complications of obstruction and bleeding. Many recent studies, most retrospective, have evaluated the risk of surgical resection in patients with advanced age and colorectal cancer (Table 4). As expected with increasing age, the operative mortality increases, but not significantly in most studies. Furthermore morbidity and mortality in older patients is often related to more advanced disease, emergency operative conditions, and comorbidities. A large review of colorectal surgery in elderly patients from Britain was recently published.35 The authors analyzed data from over 34,000 patients, including over 10,000 between the ages of 65 and 74, over 9,000 between the ages of 75 and 84, and over 2,000 patients 85 and older. The median mortality rate for each group increased with age (3% for the youngest, 6.4% for the 65 to 74, 8.6% for the 75 to 84, and 19.4 for the over 85 age group). However, when studies of only elective surgery were examined, the mortality rates declined to 1.7%, 0%, 1.0%, and 2.0%, respectively. These data underscore the fact that many of the operations in older patients were performed as an emergency, raising the morbidity and mortality considerably. This study, like so many others, showed that cancer specific survival was similar among the elderly and younger patients; age alone should not be used to deny a patient curative surgery. Survival after curative resection for colon carcinoma has been reported in some studies to be lower for patients over 70 years of age.37 However, in one series, multivariate analysis showed that
3-year survival was influenced by disease stage and type of surgical procedure performed (resection v palliation), but not age (⬎80 v ⬍ 80 years of age).38 Hospital stay was longer for those over 80, as was the cost of treatment (22% increased cost). Another series indicated that while physical status and operative mortality were worse in the elderly undergoing surgery for colorectal cancer, for the elderly who are fit, who underwent curative resection, and who survived over 30 days, 5-year survival was similar to younger patients.39 In another series, cardiopulmonary complications after colorectal surgery were increased from 1.8% in patients under 65, to 10.8% in patients 65 to 75 and 8.2% in patients over 75 years of age.6 Anastomatic leak rates were also increased from 4.2% in patients under 65 to 8.2% in those over 75 years old.6 Mortality rates in this series were also higher; however, most series show that age is not an independent factor related to surgical risk. Older patients, especially those ⱖ80, are less likely to have tumors amenable to curative resection because older patients often present with more advanced-stage disease.40 Even palliative operations, such as creation of a colostomy, often carry high mortality rates because they are frequently performed as emergency procedures.5,36 With the increase in mortality associated with emergency surgery and advanced disease stage, it is crucial that older patients are diagnosed and treated as early as possible. The role for laparoscopy-assisted colon resection is presently being evaluated in patients with colon cancer. The advantages of laparoscopic co-
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lon resection may include a decrease in postoperative pain and ileus,41 a shorter hospital stay, and a faster return to normal lifestyle than with conventional colon resection. However, whether laparoscopic resection is as safe and effective as the standard resection procedure is uncertain and is being addressed in ongoing prospective randomized clinical trials. Of additional concern are documented laparoscopic port site recurrences after resections. Thirty-five recurrences were reported over a 2-year period in one recent review of the literature.42 Other potential options for palliative treatment and control of obstruction or hemorrhage in elderly patients with advanced rectal cancer are the use of local intraluminal therapies such as electrofulguration, laser therapy, or cryotherapy.43 Laser therapy is effective for palliation in 85% to 95% of patients, and procedure-related morbidity and mortality rates are low.43 Quality of life after colon resection has not been extensively explored in the elderly population. Creating a stoma must be viewed with caution because it may be difficult for some elderly patients to manage not only physically but psychologically. For patients with liver metastases from colorectal cancer, the use of liver resection for patients with one to three liver lesions is the optimal treatment for patients with liver-only metastases. Liver resections can be performed safely in elderly patients. A recent report compared patients with liver resections at a single institution using age as the discriminating criteria.4 For patients over 70 years of age, the perioperative mortality rate was similar to patients younger than 70. Morbidity rates were 42% and 40%, respectively, for the elderly and the younger group, with the majority of the complications in the elderly being cardiopulmonary in origin. After multivariate analysis, age was not found to be related to outcome. The median hospital stay for patients ⱖ70 was only 1 day longer than for patients less than 70 years old. Morbidity, mortality, intensive care unit admission rates, and long-term survival were not different between older patients and younger patients. While it was not clear what selection criteria were used to select these elderly patients for a major hepatic resection, it was clear that these procedures in the elderly were associated with a good operative survival and an equal likelihood of cure when compared with the younger patients.
M. MARGARET KEMENY
PANCREATIC CANCER
The incidence of pancreatic cancer increases with age. In one series, over two thirds of the patients were over the age of 65 at diagnosis.44 While the cure rate for pancreatic cancer is low, it can only be achieved with surgical intervention. However, most patients with pancreatic cancer present with late-stage disease and are unresectable.44 The percentage of patients with resectable cancers is even lower for patients after the age of 70. Even for patients who are able to undergo resection, mean survival is still only 10.6 to 24.6 months.45 Pancreaticoduodenectomy is the operation of choice for lesions in the head of the pancreas, periampullary area, duodenum, and distal common bile duct. These procedures were previously associated with a complication rate and mortality rate as high as 26%. When weighed against the relatively small survival benefit after a successful resection, many viewed the procedure as an unreasonable option for treatment,46,47 especially in elderly patients. However, recent series show that the morbidity and mortality rates associated with this operation have decreased significantly and now range between 0% and 5%.48,49 Even in the elderly, mortality rates for these extensive and complicated procedures are acceptable in selected patients.3,50,51 In a review of pancreatic cancer resection in 138 patients over the age of 70, the operative mortality rate of 6% and morbidity rate of 40% was seen, which are very acceptable outcomes for pancreatic resection.3 Univariate analysis showed that a history of cardiopulmonary disease, an abnormal preoperative electrocardiogram, and an abnormal chest radiograph were predictors of complications. However, in multivariate analysis, the only factor found to be a significant predictor of complications was a blood loss of more than 2 liters. No significant differences were found in length of hospital stay, rate of intensive care unit admission, or morbidity or mortality rates between patients younger than 70 and those older than 70. Median survival for all patients was 18 months, and the 5-year survival rate was 21%. Several smaller series of pancreatic resection have reported mortality rates in elderly patients in the range of 5% to 10%, with morbidity rates of 14% to 48%.52-54 In one series from Johns Hopkins
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Table 5. Gastric Resections in the Elderly Study Schwartz et
al*65
Bonenkamp et al66
Viste et al67
Age (yr)
No. of Patients
Morbidity
Mortality
⬎70
310
47.1%
7.1%
⬎70 D1 D2
231 128 103
30% 45%
7% 18%
ⱖ80
106
34%
15%
* 85% ⬎ D1 resections.
University, no operative mortality occurred after 37 consecutive pancreaticoduodenectomies in patients over the age of 70.48 Also, no significant differences were found between the length of stay or rate of complications in patients over 70 compared with younger patients. However, the patients in this series were carefully selected and had no differences in preoperative medical risk factors when compared with younger patients. Five-year survival rates after pancreatic resection are similar in older and younger patients. One series reported a 5-year survival rate for pancreatic cancer of 17% in patients over 70 and 19% in patients less than 70 years of age.51 Periampullary tumor survival rates were better for both groups at 38% and 45%, respectively. The majority of patients with pancreatic cancer are unresectable, but many need palliation for biliary and gastric obstruction.45 The elderly patient may not tolerate bypass procedures as well a younger patient. One Veteran’s Administration study showed a significantly higher 30-day morbidity and mortality rate and lower median survival rate after bypass procedures for patients over 70.55 For all patients, the risks and benefits of bypass surgery should be individualized. The operative mortality rate for biliary bypass ranges from 4% to 33% (mean, 19%) and overall survival from 1.5 to 12 months (mean, 5.4 months).56 Several randomized series have shown biliary obstruction can often be as effectively managed as bypass, with stents placed either endoscopically or percutaneously transhepatically.57-59 Mortality rates are lower for stent placement than for surgical bypass and hospital stays are shorter. While early complication rates are lower after stent placement, long-term complication rates
such as recurrent jaundice and cholangitis are more common than with surgical bypass. Gastric outlet obstruction, although far less common as a presenting symptom, still requires operative bypass for relief. Survival after gastric bypass is often short and furthermore, gastric bypass does not always result in palliation.60 Recently, the introduction of laparoscopic techniques has provided a new method of performing gastric bypass with the potential of lowering morbidity and mortality, especially in debilitated patients. GASTRIC CANCER
In the United States, gastric cancer, like pancreatic cancer, is usually a disease of the older person, with 50% of males and 60% of females over the age of 70.61 Curative treatment requires surgical removal of the cancer. Surgical treatment is often necessary for palliation of bleeding or obstruction. Information from several Japanese series of the characteristics of gastric cancer in the elderly show no difference in symptoms at presentation or the location of disease in the stomach between younger and older patients.62,63 The incidence of vascular and lymphatic invasion has been reported to be higher in the elderly, while there is no difference in the incidence of lymph node metastases and stage at diagnosis.63,64 The exact technique for curative surgery remains controversial as to the extent of surgery. The gastric resection itself is standard, but the extent of lymphadenectomy required varies. Removal of perigastric nodes (a D1 resection) should always be performed, while removal of more extensive regional lymph nodes outside the perigas-
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tric region, termed “D2 resection,” is under scrutiny. Morbidity and mortality rates after gastric resections appear to be increased in the elderly compared with younger patients (Table 5). While preoperative risk factors are increased in the elderly, particularly cardiac and pulmonary disease, the majority of complications and deaths are caused by infection, anastomotic leak, and pulmonary problems, and are similar to those seen in younger patients.2,66-68 An important element in deciding about surgical treatment in the elderly is the impact of surgery on quality of life. One series from Japan assessed the quality of life after gastrectomy for gastric cancer in patients over 70 years of age compared with those younger than 70.69 After surgery no significant difference was found in the amount of food intake or weight change among older and younger patients. However, a significant decrease in performance status was found. Although performance status decreased after surgery in both groups, it improved in the younger patients, but remained decreased and unchanged in older patients. However, most older patients were still capable of self-care. The “health rate” and employment rate were lower after surgery for the elderly, but over half of those older patients who did not return to work felt it was not necessary for them to return rather than not possible for physical reasons. The authors concluded that the elderly should not be excluded from surgery based on quality-of-life concerns. In another smaller series of patients over 70 undergoing total gastrectomy, 70% of patients returned to “normal life” after 1 year, although the regaining of body weight was slower than in younger patients.70 Overall, the 5-year survival for curatively resected patients with gastric cancer is similar for younger and older patients.62,64 CONCLUSION
The incidence of most cancers increases with age. Breast, colorectal, gastric, and pancreatic cancers are the most common solid tumors seen by surgical oncologists in the United States, and all require surgical intervention for cure. Although the risk for surgery increases in the elderly with comorbidities, risk can be adequately evaluated to allow interventions that might potentially decrease morbidity and mortality. Appropriate surgical treatments must be offered to the elderly in a
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