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Colorectal cancer surgery in the elderly: acceptable morbidity?
The American Journal of Surgery 195 (2008) 344 –348
Colorectal cancer surgery in the elderly: acceptable morbidity? Evan S. Ong, M.D., Mohamed Alassas, M.D., Kelli Bullard Dunn, M.D., Ashwani Rajput, M.D.* Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton St., Buffalo, NY 14263, USA University at Buffalo, State University of New York, Buffalo, NY, USA Manuscript received November 26, 2007; revised manuscript December 14, 2007 Presented at the Midwest Surgical Association Fiftieth Annual Meeting, Farmington, PA, August 6, 2007.
Abstract Background: Because of the increase in the geriatric population, an increasing number of elderly patients are being treated for colorectal cancer. The purpose of this study was to evaluate perioperative morbidity and mortality in this population. Methods: A retrospective chart review was performed for patients 80 years of age or older who underwent surgery for colorectal cancer (1993–2006). Results: Ninety patients were identified, with a median age of 84 years. More than 90% presented with symptoms; the remaining were diagnosed by screening colonoscopy. Emergent surgery was required in 10%. The morbidity rate was 21% and the overall 30-day mortality rate was 1.1%. Morbidity was higher in patients who required surgery emergently. Conclusions: Despite advanced age, the majority of patients in this study did well. Postoperative morbidity was higher than in the general population, but we believe it was acceptably low in most patients. Colorectal surgery appears to be safe in most elderly patients. © 2008 Elsevier Inc. All rights reserved. Keywords: Elderly; Geriatric oncology; Colorectal cancer; Surgical outcomes
The geriatric population (⬎65 y) represents one of the fastest growing subsets of the US population. By 2030, the elderly are projected to represent 20% of the total population [1]. It is this same rapidly growing subset of the population that also currently has the highest incidence of colorectal cancer [2]. Because colorectal cancer is currently the second leading cause for cancer mortality in the United States, the treatment of colorectal cancer will have a large impact on survival in the geriatric population. However, clearly defined guidelines for the treatment and management of colorectal cancer in the geriatric population are lacking, and sporadic publications reporting outcomes of surgical care in the elderly have had mixed conclusions [3,4]. Therefore, the purpose of our study was to review the outcomes of surgical treatment in octogenarians with colorectal cancer at our institution.
* Corresponding author. Tel.: ⫹1-716-845-5807; fax: ⫹1-716-8451278. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.12.022
Methods A retrospective query of the Roswell Park Cancer Institute Tumor Registry was performed to identify all patients 80 years of age and older who were diagnosed and treated for colorectal cancer between 1993 and 2006. The Tumor Registry is maintained by a separate database manager who collects data points prospectively. Patients are contacted by the Tumor Registry at scheduled intervals to update the database and record the current status. Survival data are maintained through both Social Security death records and with regular-interval follow-up contacts. We then determined how many of these patients underwent surgical intervention. We excluded patients who had endoscopic treatment only and included only patients with histologically proven adenocarcinoma. Patient demographics, presenting signs and symptoms, method of diagnosis, stage at presentation, type of surgical treatment, 30-day morbidity and mortality, information concerning discharge placement, chemotherapy treatment, and overall survival were collected. Data were recorded and analyzed using a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA). Survival was calculated from the time of surgery. Survival data were analyzed by the Kaplan-Meier method. The study was
E.S. Ong et al. / The American Journal of Surgery 195 (2008) 344 –348
345
Fig. 1. Distribution of the percentage of colorectal cancer patients who were elderly (⬎80) and underwent surgical intervention by year (1994 –2005). Values are in percentages.
performed in compliance with the Health Insurance Portability and Accountability Act guidelines and with the approval of the Roswell Park Cancer Institute Institutional Review Board. Results A total of 894 patients with the diagnosis of colorectal cancer were identified initially. Of these, 157 patients were 80 years of age or older. Sixty-seven patients then were excluded from the study. Thirty-three did not undergo surgery and 18 underwent only endoscopic treatment. In 13 patients, data were incomplete. Three patients had nonadenocarcinoma histology (1 leiomyosarcoma, 1 neuroendocrine, and 1 small cell cancer). Therefore, a total of 90 patients were included and analyzed for this study. When we separated these patients by the year of diagnosis, we found that in our colorectal cancer population there has been an almost 5-fold increase in the percentage of elderly patients undergoing intervention since 1993 (Fig. 1). The median age of this group was 84 years (range, 80–98 y); sex was divided evenly. The vast majority of patients were Caucasian (Table 1). Most patients (91%) presented with symptoms that prompted a diagnostic evaluation. The most common symptoms were blood in the stool and anemia. The 8 patients who did not have any symptoms were diagnosed by screening colonoscopy. Surgery was performed emergently (defined as a surgery during hospitalization for the presenting symptom) in 9 patients (10%). Slightly more than half of patients had right-sided tumors and underwent right colectomy (50 patients; 55%). Three of these procedures were performed laparoscopically. Seventeen (19%) had left-sided tumors and 24 (26%) had rectal tumors. Twelve underwent sigmoidectomy. Sixteen under-
went low anterior resection, and 6 had an abdominal perineal resection. Twelve patients required a stoma (8 end colostomies and 4 loop ileostomies). After surgical resection, most patients were found to Table 1 General characteristics, presentation, and modality of diagnosis for colorectal cancer patients 80 years of age and older who underwent surgical intervention and were treated at Roswell Park Cancer Institute from 1993 to 2006 Mean age, y Range (minimum–maximum), y Sex, M/F Race, n White African American Other Presentation, n Asymptomatic Symptomatic Blood in stool Anemia Abdominal pain Change in bowel habits Obstruction* Perforation* Massive bleeding* Mass Weight loss Diagnostic examination, n Colonoscopy Screening colonoscopy Computerized tomography scan Barium enema * Surgery performed emergently
84 80–98 47/43 85 (94.5%) 3 (3.3%) 2 (2.2%) 9 (9%) 82 (91%) 34 23 7 4 5 2 4 2 1 73 (81%) 8 (9%) 14 (16%) 8 (9%)
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Fig. 2. Pathologic stage at time of surgery. Values are numbers of patients.
have stage II or III cancer (64%) (Fig. 2). A smaller number (16%) were diagnosed with stage IV disease. When these patients were divided between those who had screening colonoscopy (8 patients) versus those who had symptoms at presentation, the majority of patients who underwent screening colonoscopy were found to have stage I (50%) or II disease (25%). There were no patients with stage IV disease among those who were diagnosed with screening colonoscopy. Complications occurred in 19 patients (21%). Most of these complications (9 patients) were cardiac or pulmonary (Table 2). There were no anastomotic leaks reported. Patients who presented with symptoms requiring emergent surgical intervention had a higher complication rate (33%) compared with those patients undergoing an elective surgery (20%). There was 1 death postoperatively (30-day mortality rate, 1.1%). Interestingly, the majority of patients were discharged to home (82 patients; 91%). Four of the 7 patients who were discharged to a rehabilitation facility had postoperative complications. Of the remaining 3 patients, 1 patient was blind with no family support, another had pre-
operative generalized weakness and required a short-term admission to the rehabilitation facility, and the third patient was recovering from an abdominal perineal resection. Chemotherapy was used in 18% of stage II patients, 56% of stage III patients, and only 36% of stage IV patients. Patients were followed up for an average of 32 months (range, 2–105 mo). The overall median survival was 39 months. When overall survival was analyzed by stage, stage I patients had a median survival of 69 months and a 5-year survival rate of 77%. In comparison, stage II patients had a dramatic decrease in overall median survival of 54 months and a 5-year survival rate of 35%. Stage III patients had an overall median and 5-year survival rate of 33 months and 24%, respectively. Not surprisingly, stage IV patients had the worst survival with an overall median survival of 24 months and no 5-year survivors (Fig. 3). Comments In the United States, more than 50% of all cancers occur in the 12% of people who are older than age 65. This group is also one of the fastest-growing subsets of the US popu-
Table 2 Complications after surgical intervention Congestive heart failure exacerbation Pneumonia Stroke* Myocardial infarction* Arrhythmia Wound infection Prolonged ileus* Acute renal failure Sepsis* Intra-abdominal abscess Postoperative bleeding Death * Associated with rehabilitation.
1
2 2 1 1 4 3 2 1 1 1 1 1
0.9 0.8 0.7 Ratio of survival
0.6 0.5 0.4 0.3 0.2 0.1 0 0
20
40
60
80
100
120
Time (months)
Fig. 3. Kaplan-Meier curves of overall survival for all patients and by stage. Overall survival for all patients is shown (⽧). Overall survival by stage I (⫻), stage II (), stage III (Œ), and stage IV (●) also are plotted.
E.S. Ong et al. / The American Journal of Surgery 195 (2008) 344 –348
lation. By 2030, the elderly are projected to comprise 20% of the total population [1]. Not surprisingly, this group is predicted to account for 70% of all cancer diagnoses in the future [3]. Indeed, when we separated our own cohort of patients by the year of diagnosis, there was an almost 5-fold increase in the percentage of elderly patients with colorectal cancer who underwent surgical treatment. Although there are several studies that have looked at outcomes after surgical treatment of colorectal cancer in the elderly, the majority of these studies were either older retrospective studies that may not reflect current surgical and medical treatments [5,6] or were studies conducted abroad [3,4,7–11]. The latter studies have provided important results, however, the conclusion from these studies may not be relevant to the geriatric population of the United States. We have studied a cohort of extremely elderly patients treated at a designated cancer center in the United States in an attempt to clarify these issues. In our patients, our 30-day mortality rate was approximately 1% and our morbidity rate was 21%. Although our mortality rate was equal to or slightly better than mortality rates reported in other studies [6 –9,12], our morbidity rate was slightly higher than in the general population [3,13]. However, the morbidity rate in our study was similar to studies reporting surgical outcomes in elderly patients with colon cancer [3,4,8]. Turrentine et al [14] retrospectively reviewed surgical outcomes in elderly patients undergoing major surgeries and reported a 28% morbidity rate. A subgroup analysis of patients older than 80 years of age undergoing major surgeries found morbidity to be as high as 51%. Therefore, although our surgical morbidity was slightly higher than the general population, it was arguably as good if not better than that reported by other investigators treating elderly patients. Our surgical complications were similar to others [3,4,8,11] and most were cardiopulmonary. The patients who presented with symptoms requiring emergent surgery had higher complication rates (33%) as expected, and accounted for more than half of the patients who required placement into a rehabilitation facility. This is consistent with the findings reported by others [11,14 –16]. Overall survival in this group was 32% at 5 years. This is considerably lower than survival after colorectal surgery in the general population. One explanation could be that they presented with a later stage disease than that of the general population because most of our patients were symptomatic (91%) at initial presentation. McCarthy et al [17] reported on colorectal cancer staging at diagnosis using the Surveillance, Epidemiology and End Results–Medicare– linked database. They found the staging distribution to be as follows: stage I (including carcinoma in situ), 32%; stage II, 22%; stage III, 22%; stage IV, 20%; and unstaged 4%. Compared with their results, more of our patients presented with a later stage of disease (80% stage II or above). Interestingly, although only a small cohort, patients who had undergone screening colonoscopy were found to have earlier stage cancers compared with the majority of symptomatic patients having either locally advanced or nodal disease. Potentially, the use of screening colonoscopy could have diagnosed other patients at an earlier stage. Although the literature concerning screening colonoscopy in the elderly is
347
limited, several studies have suggested that screening colonoscopy may improve outcomes in the elderly with colon cancer by discovering them at an earlier stage [16,18,19]. In addition, we found that adjuvant chemotherapy was used less frequently in our study population. A recent analysis of all patients with colon carcinoma in the US National Cancer Data Base found that 40% of all patients younger than age 50 were treated with surgery plus chemotherapy versus only 20% of all patients aged 70 to 79 [20]. Overall, chemotherapy was delivered in only 28% of our entire study population. Although adjuvant chemotherapy should be considered in all elderly patients, realistically these patients are more likely to receive either a lower chemotherapy dose or no chemotherapy [21]. Our study has shown that surgical treatment of colorectal cancer in the octogenarian can be performed safely with acceptable morbidity and mortality. Morbidity in these patients was higher than in the general population, but not unacceptably high. Mortality was very low. Additional prospective studies will be required to determine how the surgical outcomes can be improved in this ever-increasing elderly population. References [1] U.S. Bureau of the Census, Day JC, Population Projections of the United States, by Age, Sex, Race, and Hispanic Origin: 1993 to 2050. Current Populations Reports, P25-1104, U.S. Government Printing Office, 1993. [2] Matanoski G, Tao XG, Almon L, et al. Demographics and tumor characteristics of colorectal cancers in the United States, 1998 –2001. Cancer 2006;107(Suppl):1112–20. [3] Colorectal Cancer Collaborative Group. Surgery for colorectal cancer in elderly patients: a systematic review. Lancet 2000;356:968 –74. [4] Shahir MA, Lemmens VE, van de Poll-Franse LV, et al. Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study. Eur J Cancer 2006;42:3015–21. [5] Hobler KE. Colon surgery for cancer in the very elderly. Cost and 3-year survival. Ann Surg 1986;203:129 –31. [6] Hobler KE, Howlett PA. Surgery in the very elderly. QRB Qual Rev Bull 1985;11:339 – 41. [7] Endreseth BH, Romundstad P, Myrvold HE, et al. Rectal cancer treatment of the elderly. Colorectal Dis 2006;8:471–9. [8] Law WL, Choi HK, Ho JW, et al. Outcomes of surgery for mid and distal rectal cancer in the elderly. World J Surg 2006;30:598 – 604. [9] Vivi AA, Lopes A, Cavalcanti Sde F, et al. Surgical treatment of colon and rectum adenocarcinoma in elderly patients. J Surg Oncol 1992;51:203– 6. [10] Jensen SA, Vilmar A, Sorensen JB. Adjuvant chemotherapy in elderly patients (⬎or⫽75 yr) completely resected for colon cancer stage III compared to younger patients: toxicity and prognosis. Med Oncol 2006;23:521–31. [11] Fielding LP, Phillips RK, Hittinger R. Factors influencing mortality after curative resection for large bowel cancer in elderly patients. Lancet 1989;1:595–7. [12] Araujo SE, de Paris Caravatto PP, de Campos FG, et al. Colorectal cancer among patients aged 75 years or over. Hepatogastroenterology 2007;54:427–30. [13] Gurlich R, Maruna P, Kalvach Z, et al. Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic. Arch Gerontol Geriatr 2005;41:183–90. [14] Turrentine FE, Wang H, Simpson VB, et al. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006; 203:865–77. [15] Yoo PS, Mulkeen AL, Frattini JC, et al. Assessing risk factors for adverse outcomes in emergent colorectal surgery. Surg Oncol 2006; 15:85–9.
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[16] Diggs JC, Xu F, Diaz M, et al. Failure to screen: predictors and burden of emergency colorectal cancer resection. Am J Manag Care 2007;13:157– 64. [17] McCarthy EP, Ngo LH, Chirikos TN, et al. Cancer stage at diagnosis and survival among persons with Social Security Disability Insurance on Medicare. Health Serv Res 2007;42:611–28. [18] Ure T, Dehghan K, Vernava AM 3rd, et al. Colonoscopy in the elderly. Low risk, high yield. Surg Endosc 1995;9:505– 8. [19] Zerey M, Paton BL, Khan PD, et al. Colonoscopy in the very elderly: a review of 157 cases. Surg Endosc 2007;21:1806 –9. [20] Jessup JM, McGinnis LS, Steele GD Jr, et al. The National Cancer Data Base. Report on colon cancer. Cancer 1996;78:918 –26. [21] Sundararajan V, Grann VR, Jacobson JS, et al. Variations in the use of adjuvant chemotherapy for node-positive colon cancer in the elderly: a population-based study. Cancer J 2001;7:213– 8.
Discussion Conor P. Delaney, M.D. (Cleveland, OH): The authors have reviewed a series of 90 patients, all over 80 years of age, seen over approximately a 10-year period, and have presented their clinical outcomes for this fairly high-risk group of patients. All the treatment was by a specialist colorectal team at Roswell Park, and clinical outcomes were really excellent. Who maintained this database, and were the definitions used standardized in any way? How many of these for patients operated on up to 15 years ago may have been operated on from a distance and returned to a local area and you may not have heard about further? How did you define 30-day mortalities? Were many of these simply your in-hospital mortality, it being hard to find 30-day mortalities? And as a measure of proving your mortality rate, did you do anything like look at the Social Security death records to try and confirm your mortality? In regards to laparoscopy, we and others have published on benefits in the elderly. You had 3 cases done on the right side that were laparoscopic. Did you use laparoscopy at all on the left side for rectal cancer and is this something you are considering?
Finally, you talk very little about resource utilization. Elderly patients often have a longer hospital stay and need more use of skilled nursing facilities. You mentioned your use of skilled nursing facilities. Do you have any data on the patients’ hospital stay or readmission rates? Evan S. Ong, M.D.: In terms of data collection, we use a tumor registry maintained by people that are dedicated to collecting patient information. When we performed our retrospective analysis and a retrospective review, we identified these patients to the tumor registry primarily. They contain the data, including their death and certain data points that were included in the study. They also follow-up with their Social Security death records and they maintain records concerning mortality. So they are fairly accurate. In terms of patients that do reside a long distance away, the tumor registry contacts the families or the patient to keep this registry updated. We did not implement laparoscopy for our left-sided or rectal lesions. However, we are increasing the use of laparoscopy currently in these type of lesions, and we agree that laparoscopy should be a consideration, particularly in elderly patients. Your fourth question was concerning longer hospital stay and frequent use of skilled nursing in the elderly patient, although we were able to identify those patients that required either a skilled nursing facility or reimplementation, we did not collect data concerning hospital stay or readmission, so I am unable to comment on that information. William C. Cirocco, M.D. (Shawnee Mission, KS): I was interested in findings on the right side of predominance of your colorectal cancers. Any idea if you had maybe a high percentage of Lynch syndrome patients? Evan S. Ong, M.D.: We did not look at any genetic data for these patients.
Colorectal cancer surgery in the elderly: acceptable morbidity? Evan S. Ong, M.D., Mohamed Alassas, M.D., Kelli Bullard Dunn, M.D., Ashwani Rajput, M.D.* Department of Surgical Oncology, Roswell Park Cancer Institute, Elm and Carlton St., Buffalo, NY 14263, USA University at Buffalo, State University of New York, Buffalo, NY, USA Manuscript received November 26, 2007; revised manuscript December 14, 2007 Presented at the Midwest Surgical Association Fiftieth Annual Meeting, Farmington, PA, August 6, 2007.
Abstract Background: Because of the increase in the geriatric population, an increasing number of elderly patients are being treated for colorectal cancer. The purpose of this study was to evaluate perioperative morbidity and mortality in this population. Methods: A retrospective chart review was performed for patients 80 years of age or older who underwent surgery for colorectal cancer (1993–2006). Results: Ninety patients were identified, with a median age of 84 years. More than 90% presented with symptoms; the remaining were diagnosed by screening colonoscopy. Emergent surgery was required in 10%. The morbidity rate was 21% and the overall 30-day mortality rate was 1.1%. Morbidity was higher in patients who required surgery emergently. Conclusions: Despite advanced age, the majority of patients in this study did well. Postoperative morbidity was higher than in the general population, but we believe it was acceptably low in most patients. Colorectal surgery appears to be safe in most elderly patients. © 2008 Elsevier Inc. All rights reserved. Keywords: Elderly; Geriatric oncology; Colorectal cancer; Surgical outcomes
The geriatric population (⬎65 y) represents one of the fastest growing subsets of the US population. By 2030, the elderly are projected to represent 20% of the total population [1]. It is this same rapidly growing subset of the population that also currently has the highest incidence of colorectal cancer [2]. Because colorectal cancer is currently the second leading cause for cancer mortality in the United States, the treatment of colorectal cancer will have a large impact on survival in the geriatric population. However, clearly defined guidelines for the treatment and management of colorectal cancer in the geriatric population are lacking, and sporadic publications reporting outcomes of surgical care in the elderly have had mixed conclusions [3,4]. Therefore, the purpose of our study was to review the outcomes of surgical treatment in octogenarians with colorectal cancer at our institution.
* Corresponding author. Tel.: ⫹1-716-845-5807; fax: ⫹1-716-8451278. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.12.022
Methods A retrospective query of the Roswell Park Cancer Institute Tumor Registry was performed to identify all patients 80 years of age and older who were diagnosed and treated for colorectal cancer between 1993 and 2006. The Tumor Registry is maintained by a separate database manager who collects data points prospectively. Patients are contacted by the Tumor Registry at scheduled intervals to update the database and record the current status. Survival data are maintained through both Social Security death records and with regular-interval follow-up contacts. We then determined how many of these patients underwent surgical intervention. We excluded patients who had endoscopic treatment only and included only patients with histologically proven adenocarcinoma. Patient demographics, presenting signs and symptoms, method of diagnosis, stage at presentation, type of surgical treatment, 30-day morbidity and mortality, information concerning discharge placement, chemotherapy treatment, and overall survival were collected. Data were recorded and analyzed using a Microsoft Excel spreadsheet (Microsoft Corp., Redmond, WA). Survival was calculated from the time of surgery. Survival data were analyzed by the Kaplan-Meier method. The study was
E.S. Ong et al. / The American Journal of Surgery 195 (2008) 344 –348
345
Fig. 1. Distribution of the percentage of colorectal cancer patients who were elderly (⬎80) and underwent surgical intervention by year (1994 –2005). Values are in percentages.
performed in compliance with the Health Insurance Portability and Accountability Act guidelines and with the approval of the Roswell Park Cancer Institute Institutional Review Board. Results A total of 894 patients with the diagnosis of colorectal cancer were identified initially. Of these, 157 patients were 80 years of age or older. Sixty-seven patients then were excluded from the study. Thirty-three did not undergo surgery and 18 underwent only endoscopic treatment. In 13 patients, data were incomplete. Three patients had nonadenocarcinoma histology (1 leiomyosarcoma, 1 neuroendocrine, and 1 small cell cancer). Therefore, a total of 90 patients were included and analyzed for this study. When we separated these patients by the year of diagnosis, we found that in our colorectal cancer population there has been an almost 5-fold increase in the percentage of elderly patients undergoing intervention since 1993 (Fig. 1). The median age of this group was 84 years (range, 80–98 y); sex was divided evenly. The vast majority of patients were Caucasian (Table 1). Most patients (91%) presented with symptoms that prompted a diagnostic evaluation. The most common symptoms were blood in the stool and anemia. The 8 patients who did not have any symptoms were diagnosed by screening colonoscopy. Surgery was performed emergently (defined as a surgery during hospitalization for the presenting symptom) in 9 patients (10%). Slightly more than half of patients had right-sided tumors and underwent right colectomy (50 patients; 55%). Three of these procedures were performed laparoscopically. Seventeen (19%) had left-sided tumors and 24 (26%) had rectal tumors. Twelve underwent sigmoidectomy. Sixteen under-
went low anterior resection, and 6 had an abdominal perineal resection. Twelve patients required a stoma (8 end colostomies and 4 loop ileostomies). After surgical resection, most patients were found to Table 1 General characteristics, presentation, and modality of diagnosis for colorectal cancer patients 80 years of age and older who underwent surgical intervention and were treated at Roswell Park Cancer Institute from 1993 to 2006 Mean age, y Range (minimum–maximum), y Sex, M/F Race, n White African American Other Presentation, n Asymptomatic Symptomatic Blood in stool Anemia Abdominal pain Change in bowel habits Obstruction* Perforation* Massive bleeding* Mass Weight loss Diagnostic examination, n Colonoscopy Screening colonoscopy Computerized tomography scan Barium enema * Surgery performed emergently
84 80–98 47/43 85 (94.5%) 3 (3.3%) 2 (2.2%) 9 (9%) 82 (91%) 34 23 7 4 5 2 4 2 1 73 (81%) 8 (9%) 14 (16%) 8 (9%)
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E.S. Ong et al. / The American Journal of Surgery 195 (2008) 344 –348
Fig. 2. Pathologic stage at time of surgery. Values are numbers of patients.
have stage II or III cancer (64%) (Fig. 2). A smaller number (16%) were diagnosed with stage IV disease. When these patients were divided between those who had screening colonoscopy (8 patients) versus those who had symptoms at presentation, the majority of patients who underwent screening colonoscopy were found to have stage I (50%) or II disease (25%). There were no patients with stage IV disease among those who were diagnosed with screening colonoscopy. Complications occurred in 19 patients (21%). Most of these complications (9 patients) were cardiac or pulmonary (Table 2). There were no anastomotic leaks reported. Patients who presented with symptoms requiring emergent surgical intervention had a higher complication rate (33%) compared with those patients undergoing an elective surgery (20%). There was 1 death postoperatively (30-day mortality rate, 1.1%). Interestingly, the majority of patients were discharged to home (82 patients; 91%). Four of the 7 patients who were discharged to a rehabilitation facility had postoperative complications. Of the remaining 3 patients, 1 patient was blind with no family support, another had pre-
operative generalized weakness and required a short-term admission to the rehabilitation facility, and the third patient was recovering from an abdominal perineal resection. Chemotherapy was used in 18% of stage II patients, 56% of stage III patients, and only 36% of stage IV patients. Patients were followed up for an average of 32 months (range, 2–105 mo). The overall median survival was 39 months. When overall survival was analyzed by stage, stage I patients had a median survival of 69 months and a 5-year survival rate of 77%. In comparison, stage II patients had a dramatic decrease in overall median survival of 54 months and a 5-year survival rate of 35%. Stage III patients had an overall median and 5-year survival rate of 33 months and 24%, respectively. Not surprisingly, stage IV patients had the worst survival with an overall median survival of 24 months and no 5-year survivors (Fig. 3). Comments In the United States, more than 50% of all cancers occur in the 12% of people who are older than age 65. This group is also one of the fastest-growing subsets of the US popu-
Table 2 Complications after surgical intervention Congestive heart failure exacerbation Pneumonia Stroke* Myocardial infarction* Arrhythmia Wound infection Prolonged ileus* Acute renal failure Sepsis* Intra-abdominal abscess Postoperative bleeding Death * Associated with rehabilitation.
1
2 2 1 1 4 3 2 1 1 1 1 1
0.9 0.8 0.7 Ratio of survival
0.6 0.5 0.4 0.3 0.2 0.1 0 0
20
40
60
80
100
120
Time (months)
Fig. 3. Kaplan-Meier curves of overall survival for all patients and by stage. Overall survival for all patients is shown (⽧). Overall survival by stage I (⫻), stage II (), stage III (Œ), and stage IV (●) also are plotted.
E.S. Ong et al. / The American Journal of Surgery 195 (2008) 344 –348
lation. By 2030, the elderly are projected to comprise 20% of the total population [1]. Not surprisingly, this group is predicted to account for 70% of all cancer diagnoses in the future [3]. Indeed, when we separated our own cohort of patients by the year of diagnosis, there was an almost 5-fold increase in the percentage of elderly patients with colorectal cancer who underwent surgical treatment. Although there are several studies that have looked at outcomes after surgical treatment of colorectal cancer in the elderly, the majority of these studies were either older retrospective studies that may not reflect current surgical and medical treatments [5,6] or were studies conducted abroad [3,4,7–11]. The latter studies have provided important results, however, the conclusion from these studies may not be relevant to the geriatric population of the United States. We have studied a cohort of extremely elderly patients treated at a designated cancer center in the United States in an attempt to clarify these issues. In our patients, our 30-day mortality rate was approximately 1% and our morbidity rate was 21%. Although our mortality rate was equal to or slightly better than mortality rates reported in other studies [6 –9,12], our morbidity rate was slightly higher than in the general population [3,13]. However, the morbidity rate in our study was similar to studies reporting surgical outcomes in elderly patients with colon cancer [3,4,8]. Turrentine et al [14] retrospectively reviewed surgical outcomes in elderly patients undergoing major surgeries and reported a 28% morbidity rate. A subgroup analysis of patients older than 80 years of age undergoing major surgeries found morbidity to be as high as 51%. Therefore, although our surgical morbidity was slightly higher than the general population, it was arguably as good if not better than that reported by other investigators treating elderly patients. Our surgical complications were similar to others [3,4,8,11] and most were cardiopulmonary. The patients who presented with symptoms requiring emergent surgery had higher complication rates (33%) as expected, and accounted for more than half of the patients who required placement into a rehabilitation facility. This is consistent with the findings reported by others [11,14 –16]. Overall survival in this group was 32% at 5 years. This is considerably lower than survival after colorectal surgery in the general population. One explanation could be that they presented with a later stage disease than that of the general population because most of our patients were symptomatic (91%) at initial presentation. McCarthy et al [17] reported on colorectal cancer staging at diagnosis using the Surveillance, Epidemiology and End Results–Medicare– linked database. They found the staging distribution to be as follows: stage I (including carcinoma in situ), 32%; stage II, 22%; stage III, 22%; stage IV, 20%; and unstaged 4%. Compared with their results, more of our patients presented with a later stage of disease (80% stage II or above). Interestingly, although only a small cohort, patients who had undergone screening colonoscopy were found to have earlier stage cancers compared with the majority of symptomatic patients having either locally advanced or nodal disease. Potentially, the use of screening colonoscopy could have diagnosed other patients at an earlier stage. Although the literature concerning screening colonoscopy in the elderly is
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limited, several studies have suggested that screening colonoscopy may improve outcomes in the elderly with colon cancer by discovering them at an earlier stage [16,18,19]. In addition, we found that adjuvant chemotherapy was used less frequently in our study population. A recent analysis of all patients with colon carcinoma in the US National Cancer Data Base found that 40% of all patients younger than age 50 were treated with surgery plus chemotherapy versus only 20% of all patients aged 70 to 79 [20]. Overall, chemotherapy was delivered in only 28% of our entire study population. Although adjuvant chemotherapy should be considered in all elderly patients, realistically these patients are more likely to receive either a lower chemotherapy dose or no chemotherapy [21]. Our study has shown that surgical treatment of colorectal cancer in the octogenarian can be performed safely with acceptable morbidity and mortality. Morbidity in these patients was higher than in the general population, but not unacceptably high. Mortality was very low. Additional prospective studies will be required to determine how the surgical outcomes can be improved in this ever-increasing elderly population. References [1] U.S. Bureau of the Census, Day JC, Population Projections of the United States, by Age, Sex, Race, and Hispanic Origin: 1993 to 2050. Current Populations Reports, P25-1104, U.S. Government Printing Office, 1993. [2] Matanoski G, Tao XG, Almon L, et al. Demographics and tumor characteristics of colorectal cancers in the United States, 1998 –2001. Cancer 2006;107(Suppl):1112–20. [3] Colorectal Cancer Collaborative Group. Surgery for colorectal cancer in elderly patients: a systematic review. Lancet 2000;356:968 –74. [4] Shahir MA, Lemmens VE, van de Poll-Franse LV, et al. Elderly patients with rectal cancer have a higher risk of treatment-related complications and a poorer prognosis than younger patients: a population-based study. Eur J Cancer 2006;42:3015–21. [5] Hobler KE. Colon surgery for cancer in the very elderly. Cost and 3-year survival. Ann Surg 1986;203:129 –31. [6] Hobler KE, Howlett PA. Surgery in the very elderly. QRB Qual Rev Bull 1985;11:339 – 41. [7] Endreseth BH, Romundstad P, Myrvold HE, et al. Rectal cancer treatment of the elderly. Colorectal Dis 2006;8:471–9. [8] Law WL, Choi HK, Ho JW, et al. Outcomes of surgery for mid and distal rectal cancer in the elderly. World J Surg 2006;30:598 – 604. [9] Vivi AA, Lopes A, Cavalcanti Sde F, et al. Surgical treatment of colon and rectum adenocarcinoma in elderly patients. J Surg Oncol 1992;51:203– 6. [10] Jensen SA, Vilmar A, Sorensen JB. Adjuvant chemotherapy in elderly patients (⬎or⫽75 yr) completely resected for colon cancer stage III compared to younger patients: toxicity and prognosis. Med Oncol 2006;23:521–31. [11] Fielding LP, Phillips RK, Hittinger R. Factors influencing mortality after curative resection for large bowel cancer in elderly patients. Lancet 1989;1:595–7. [12] Araujo SE, de Paris Caravatto PP, de Campos FG, et al. Colorectal cancer among patients aged 75 years or over. Hepatogastroenterology 2007;54:427–30. [13] Gurlich R, Maruna P, Kalvach Z, et al. Colon resection in elderly patients: comparison of data of a single surgical department with collective data from the Czech Republic. Arch Gerontol Geriatr 2005;41:183–90. [14] Turrentine FE, Wang H, Simpson VB, et al. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg 2006; 203:865–77. [15] Yoo PS, Mulkeen AL, Frattini JC, et al. Assessing risk factors for adverse outcomes in emergent colorectal surgery. Surg Oncol 2006; 15:85–9.
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[16] Diggs JC, Xu F, Diaz M, et al. Failure to screen: predictors and burden of emergency colorectal cancer resection. Am J Manag Care 2007;13:157– 64. [17] McCarthy EP, Ngo LH, Chirikos TN, et al. Cancer stage at diagnosis and survival among persons with Social Security Disability Insurance on Medicare. Health Serv Res 2007;42:611–28. [18] Ure T, Dehghan K, Vernava AM 3rd, et al. Colonoscopy in the elderly. Low risk, high yield. Surg Endosc 1995;9:505– 8. [19] Zerey M, Paton BL, Khan PD, et al. Colonoscopy in the very elderly: a review of 157 cases. Surg Endosc 2007;21:1806 –9. [20] Jessup JM, McGinnis LS, Steele GD Jr, et al. The National Cancer Data Base. Report on colon cancer. Cancer 1996;78:918 –26. [21] Sundararajan V, Grann VR, Jacobson JS, et al. Variations in the use of adjuvant chemotherapy for node-positive colon cancer in the elderly: a population-based study. Cancer J 2001;7:213– 8.
Discussion Conor P. Delaney, M.D. (Cleveland, OH): The authors have reviewed a series of 90 patients, all over 80 years of age, seen over approximately a 10-year period, and have presented their clinical outcomes for this fairly high-risk group of patients. All the treatment was by a specialist colorectal team at Roswell Park, and clinical outcomes were really excellent. Who maintained this database, and were the definitions used standardized in any way? How many of these for patients operated on up to 15 years ago may have been operated on from a distance and returned to a local area and you may not have heard about further? How did you define 30-day mortalities? Were many of these simply your in-hospital mortality, it being hard to find 30-day mortalities? And as a measure of proving your mortality rate, did you do anything like look at the Social Security death records to try and confirm your mortality? In regards to laparoscopy, we and others have published on benefits in the elderly. You had 3 cases done on the right side that were laparoscopic. Did you use laparoscopy at all on the left side for rectal cancer and is this something you are considering?
Finally, you talk very little about resource utilization. Elderly patients often have a longer hospital stay and need more use of skilled nursing facilities. You mentioned your use of skilled nursing facilities. Do you have any data on the patients’ hospital stay or readmission rates? Evan S. Ong, M.D.: In terms of data collection, we use a tumor registry maintained by people that are dedicated to collecting patient information. When we performed our retrospective analysis and a retrospective review, we identified these patients to the tumor registry primarily. They contain the data, including their death and certain data points that were included in the study. They also follow-up with their Social Security death records and they maintain records concerning mortality. So they are fairly accurate. In terms of patients that do reside a long distance away, the tumor registry contacts the families or the patient to keep this registry updated. We did not implement laparoscopy for our left-sided or rectal lesions. However, we are increasing the use of laparoscopy currently in these type of lesions, and we agree that laparoscopy should be a consideration, particularly in elderly patients. Your fourth question was concerning longer hospital stay and frequent use of skilled nursing in the elderly patient, although we were able to identify those patients that required either a skilled nursing facility or reimplementation, we did not collect data concerning hospital stay or readmission, so I am unable to comment on that information. William C. Cirocco, M.D. (Shawnee Mission, KS): I was interested in findings on the right side of predominance of your colorectal cancers. Any idea if you had maybe a high percentage of Lynch syndrome patients? Evan S. Ong, M.D.: We did not look at any genetic data for these patients.