VB.3 Colorectal cancer surgery in the elderly

Faculty abstracts / Critical Reviews in Oncology/Hematology 64 (2007) S11–S28 the 63, mostly mobile, screening units. The National Evaluation Team (NETB) monitors the programme and annually reports on outcome parameters as participation, referrals, screen-detected and interval breast cancers, breast cancer incidence and mortality, all based on aggregated regional data. For this study, we used data over the years 1998–2005. Results: In total, 5.43 million women were screened in 1998–2005, of whom 711,029 aged 70–75. The participation rate was 81.0% for ages 50–69 and 71.2% for ages 70–75. In the latter, participation increased from 62.5% in 1998 to 77.1% in 2005. Per 1000 women screened, 12.4 aged 50–69 years were referred for diagnostic work-up, and 16.4 aged 70–75. The breast cancer detection rate was 4.5 and 7.9 per 1000 women screened, respectively, resulting in a positive predictive value of mammography of 36% and 48%. Except a higher proportion of DCIS in younger women (13.6% vs. 10.5%), screen-detected tumour stage distribution did not differ substantially between the two age categories. Assuming a lag time of 5–10 years, breast cancer mortality among women aged 75–84 was 18.1% lower in 2005 compared to 1995–1997, and showed a similar pattern of decline as previously found in women aged 50–69 (25.5% lower breast cancer mortality in 2005). Conclusions: The results of our study confirm that screening woman up to 75 years is appropriate in a well-organised mammography programme of high quality. It might still be effective for somewhat higher ages, but the balance between benefits and harms of a population-based programme will become less favourable with a higher upper age limit.

16.15–17.10

Parallel Session V B. Surgical Oncology VB.1 16.15–16.30 Is age a factor in surgical management of liver metastases? B.L. van Leeuwen ∗ , N. De’Liguori Carino, G.J. Poston, R.A. Audisio. Department of Surgery, University of Liverpool, UK Hepatic resection of liver metastases in the elderly is feasible, safe and may offer long time survival to a substantial percentage of patients. Several selection criteria are of importance in this subgroup of patients: the presence of liver cirrhosis (Child Pugh stage B and C) particularly in patients >80 yrs is a contraindication for resectional surgery. Comorbidities are not a contraindication for hepatic resection. Although not evidence based, ASA grade III or more is considered as a contraindication. In the presence of extrahepatic disease and 3 or more factors of the modified clinical risk score by Mazzoni the benefit of hepatic resection is also doubtful. We strongly recommend considering senior patients for surgical treatment whenever possible.

VB.2 16.35–16.50 Preoperative assessment of elderly cancer patients undergoing elective surgery on behalf of PACE collaborators R.A. Audisio. University of Liverpool, UK Background: Several elderly cancer patients do not receive the appropriate surgical management for solid tumours because they are considered unfit for treatment as a consequence of inaccurate estimation of the operative risk. To tailor the treatment of oncogeriatric series, oncologists are now starting to use a Comprehensive Geriatric Assessment (CGA). We investigated on the value of CGA in assessing the suitability of elderly patients for surgical intervention. Patients & Methods: Preoperative Assessment of Cancer in the Elderly (PACE) incorporates a validated CGA tool together with an assessment of fatigue, performance status (PS) and the anaesthesiologist’s evaluation of operative risk (ASA). An international prospective study was conducted on 460 consecutive elderly cancer patients receiving PACE

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prior to elective surgery. Mortality, postoperative complications and length of hospital stay were recorded. Results: Poor health in relation to disability according to an assessment of Instrumental Activities of Daily Living (ADL), fatigue and PS were associated with 50% increase in the relative risk of postoperative complications. A multivariate Cox regression model identified moderate/severe fatigue, dependent IADL and PS as the most important predictors of post-surgical complications. Disability assessed by ADL, IADL and PS were associated with a prolonged hospital stay. No association correlated to postoperative mortality, due to the minute mortality rate (3.5%) observed throughout the whole series. Conclusions: PACE is a 20-minute interview that correlates with shortterm post-surgical outcomes. It represents a valuable tool in enhancing the decision process concerning the candidacy of elderly cancer patients for surgical intervention and can reduce inappropriate age-related inequity in access to surgical intervention. It is recommended that PACE be used routinely in surgical practice. We are encouraged that several research projects and trial proposals are now adopting PACE in their methodologies.

VB.3 Colorectal cancer surgery in the elderly

16.55–17.10

E. del Valle Hernández. Hospital General Universitario Gregorio Marañón, Madrid, Spain The incidence of colorectal cancer (CRC) is increasing, being now the second cause of cancer mortality among men and women in western countries. At the same time, the aging of the population, in a cancer that increases the incidence with age, makes that a greater number of patients will need adequate treatment in the next future and being an ethical dilemma to offer the best option. Surgery remains the cornerstone in the treatment of CRC. The multidisciplinary approach in the treatment of CRC in stages II–III makes that in some circumstances, elderly patients are considered unfit and could receive suboptimal surgery. It is well established that the age is not by itself a limitation for optimal treatment. Postoperative mortality, morbidity and long term survival after cancer surgery is not affected by chronological age on its own. The most important issue is to determine the individualized surgical risk. There are several tools directed to evaluate functional, physical, mental status and co-morbidities in the elderly, being under evaluation a new composite instrument: the preoperative assessment of cancer in the elderly (PACE). When treating elderly CRC patients there are three issues that merit special attention: nutrition, psychological distress and information. Elderly patients with CRC present as surgical emergencies in up to 40% of cases (obstruction, perforation), offering in this situations sometimes suboptimal surgery and adjuvant treatment. Is perhaps in these instances, when the surgeon must be more alert and use an accurate preoperative evaluation in order to offer the best treatment option. The stenting of an obstructed lesion of left side, sigmoid colon and upper rectum can be a good alternative especially in these aged patients, converting an emergency procedure in an elective operation after restoring hydro-electrolytic and metabolic alterations as well as an adequate staging of the disease. Laparoscopic assisted colectomy has proven to be safe and the efficacy similar to open surgery after the results of the COLOR study and a recent meta-analysis. In rectal cancer, the total mesorectal excision (TME) is the standard surgical treatment. TME when properly executed has demonstrated a significant improvement in local recurrence, having elderly patients functional and manometric results after low anterior resections no worse than younger population. Elderly patients have significantly more problems in care of stomas, for this reason, in this subgroup of patients local excision of early cancers is more advocated. The expanding use of Transanal Endoscopic Microsurgery (TEM) can aid in this form of treatment. Selected patients after neoadjuvant treatment

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Faculty abstracts / Critical Reviews in Oncology/Hematology 64 (2007) S11–S28

for T3 low rectal lesions with good endoscopic and imaging response can be candidates of local excision, being initial results very promising. Conclusion: There is not correlation between age and outcome following surgery for CRC. The appropriate operation for elderly patients must be based in an adequate individualized assessment of preoperative risk factors. In elderly suitable patients surgeons must provide optimal surgery.

Saturday, November 10, 2007 07.30–8.15

Breakfast Session. Meet the Experts Remark: Same session as on November 9, see abstracts page S11.

VB.4 Lung cancer surgery in the elderly

17.15–17.30

F. Gonzalez-Aragoneses. Gregorio Marañon Hospital, Department of Thoracic Surgery, Madrid, Spain Lung cancer management in the older patient is a growing concern, particularly with the increasing geriatric population. As life expectancy increases, so will the incidence of lung cancer. The choice of the treatment will be influenced by the age of the patient, the stage of their cancer, their performance status, their estimated survival, and quality of life with and without surgery. A careful patient evaluation and selection is necessary to identify patients who will benefit most from resection. It is necessary to keep morbidity and mortality low, and an advanced age is known to be associated with increased comorbidities. Therefore, these patients should be evaluated not only regarding the clinical stage of the tumor but also for major organs functions, and the presence of any concomitant diseases (cardiovascular, COPD, diabetes, malnutrition). Furthermore, the daily activity of patients and the support of their family are also important factors that influence the decision of surgical treatment. Resection is often not recommended to the elderly. This reluctance is based on the expectation that they have a limited life expectancy, the rate of complications and death following surgery is very high, and radiation therapy or observation alone yield similar results. However, with the improvements in surgical and anesthetic technique, a strict patient selection and a careful selection of surgical procedure contributes to a lower occurrence of morbidity and mortality. To maintain the quality of life, we can perform limited resection and video-assisted thoracic surgery for stage I NSCLC with substantial survival benefit. It is very important to avoid pneumonectomy whenever as possible by the use of parenchyma sparing procedures as bronchoplasty. Radiotherapy has achieved a result inferior to the survival after surgical resection en patients 70 years or older with clinical stage I NSCLC. In the case of very high risk patients, it is possible to choose an alternative treatment such as chemo-radiotherapy. In the postoperative care we need an aggressive physical therapy, early ambulation, and an acute pulmonary rehabilitation. Elderly patients have an increased incidence of cardiac (arrhythmia) and respiratory (pneumonia) postoperative complications. Considerable variation in outcome has been reported, with operative mortality ranging from zero to 16%. Recent studies have demonstrated a decreased postoperative mortality rate due to advances in preoperative and postoperative care and improved surgical techniques. Age is an independent predictor of postsurgical survival in NSCLC patients. Previous series reported 5-year survival rates ranging from 32% to 55%. Extent of resection and pathologic stage has a significant prognostic value in terms of long-term survival. Multivariate analysis identifies advanced tumor stage, lower ASA physical status, and low FEV1 as factors associated with poorer long-term survival. Age alone should not contraindicate pulmonary resection for lung cancer. Surgery remains the optimal treatment for patients who are deemed to have resectable disease, even in the octogenarians group. Appropriately selected with early stage disease should be offered anatomic surgical resection for cure.

08.30–10.00

Parallel Session VI A. Prostate Cancer VIA.1 08.30–08.45 SIOG (International Society of Geriatric Oncology) prostate cancer guidelines proposals in senior adult men J.P. Droz ∗ , L. Balducci, M. Bolla, M. Emberton, J. Fitzpatrick, S. Joniau, M. Kattan, S. Monfardini, J. Moul, A. Naeim, H. van Poppel, F. Saad, C. Sternberg. *Centre Léon Bérard, Lyon, France Introduction: Prostate cancer incidence increases with age, with a median age at diagnosis of 68 years. Due to the increased life expectancy, prostate cancer represents a major problem of public health. Management of prostate cancer in senior adult men represents a major challenge for the future. No specific guideline has previously been published on the management of prostate cancer in older men (>70 years). The SIOG has developed a proposal of recommendations in this setting. Methods: A systematic bibliographical search focused on screening, diagnostic procedures, treatment options for localized, locally advanced prostate cancer and metastatic disease in senior adults has be done. Specific aspects of the geriatric approach were emphasized, as evaluation of health status (nutritional, cognitive, thymic, physical and psycho-social evaluations) and screening for vulnerability and frailty. Attention was drawn on consequences of androgen deprivation and complications of local treatment, mainly incontinence. The collected material has been reviewed and discussed by a scientific panel including urologists, radiation oncologists, medical oncologists and geriatricians from both Europe and North America. Results: The consensus has been to use either EAU or NCCN clinical recommendations for prostate cancer treatment. They are adapted to health status evaluation based on Instrumental Activity daily Living (IADL) activities, comorbidities evaluation by CISR-G, screenig of dementia. Patients in group 1 (no abnormality) are likely to receive the same treatment as younger patients, patients in group 2 (one impairement in IADL, one non-controled comorbidity) will receive standard treatment after medical intervention, patients in group 3 (major IADL or cognitive impairement, several non-controled comorbidities) will receive adapted treatment, patients in group 4 (dependant) will receive only symptomatic palliative treatment. Conclusions: Treatment will be adapted to health status. Specific prospective studies in senior adult men with prostate cancer are warranted.

VIA.2 08.50–09.05 Prostate cancer – Multidisciplinary approach: a key to success J. Bellmunt. University Hospital del Mar, Barcelona, Spain The worldwide population is ageing as life expectancy increases. It is expected that in the next 25 years, the global population aged ≥65 years is likely to grow by 88% and in 2025 four out of 10 people dying will be ≥75 years [1]. Prostate cancer is still primarily a disease of older men. Although