In the first 50 years of the new millennium, the percentage of Americans over the age of 65 is expected to double [50] from 35 million to 70 million. Since the incidence of cancer increases exponentially with advancing age, it is expected that there will be a significant swell in the number of elderly patients diagnosed with cancer. It is projected that by the year 2030, the number of cancers in the elderly will reach 1.5 million [127] and will exceed 2.6 million by 2050 [50].
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1 Introduction
In the first 50 years of the new millennium, the percentage of Americans over the age of 65 is expected to double [46] from 35 million to 70 million. Since the incidence of cancer increases exponentially with advancing age, it is expected that there will be a significant swell in the number of elderly patients diagnosed with cancer. It is projected that by the year 2030, the number of cancers in the elderly will reach 1.5 million [120] and will exceed 2.6 million by 2050 [46]. People over age 65 account for 60% of newly diagnosed malignancies and 70% of all cancer deaths [17]. The incidence of cancer is 10 times greater in the population over 65 compared to those younger, and the cancer death rate is 16 times greater in the population over 65 years of age. In 2005, cancer was the leading cause of death for Americans between the ages of 60 and 79 [71].
Surgery remains the best treatment modality to cure solid tumors regardless of age. Surgery is instrumental for diagnosis, resection with curative intent, or palliation. Since the population of the United States is not only growing but also aging, the number of elderly patients with cancers requiring surgical intervention can be expected to rise.
Life expectancy is often underestimated for the elderly. According to the National Vital Statistics, the life expectancy of a girl born in 2004, the last year for which data are available, is 80.4 years, while it is 75.2 years for a boy [117]. The life expectancy of a 65-year-old female and a same-aged male is an additional 20 and 17.1 years, respectively, while that of a 75-year-old female and a same-aged male is 12.8 and 10.7 years, respectively. Thus, inadequate initial therapy for someone diagnosed with cancer at an older age can result in recurrence or metastases and death from cancer—outcomes that may have been preventable or avoidable with correct treatment at the outset.
Surgery is the mainstay of treatment of the tumors common in the elderly such as colorectal, breast, gastric, and pancreatic cancers. With adequate preoperative evaluation, surgical treatment for the elderly should not be different from that offered to younger groups; therefore, the standard of care should not be based on a patient’s age.
Unfortunately, scientific data from randomized studies are often not readily available for older populations because they were more likely to be excluded from clinical trials. Older patients are more likely to reside in rural areas where treatment facilities are few and farther apart. For example, in 2002, 24% of Americans aged 65 or older lived in rural communities, compared to only 19% of the general population. More pronounced is the fact that between 1992 and 2002, the number of Americans aged 75 and older who lived in rural areas increased by 17% compared to an overall decrease in the rural population during that time period [46].
Studies that are available are retrospective and often display considerable bias in the patients chosen for certain treatments, especially surgical procedures. Many biases influence the selection of therapy in the elderly. Concerns stem from what is perceived as limited life expectancy, the presence of comorbid disease, decreased functional status, alterations in mental status, limitations in economic resources, and assumed inability to tolerate treatment. The influence of these biases may affect survival from cancer in the elderly.
In one study, factors that influenced survival up to 10 years after the diagnosis of cancer in patients over 65 years of age with cancers of the colon, rectum, breast, and prostate were health status (comorbidity, functional status, level of activity), socioeconomic status (income and education level), cognitive status, and availability of social support [58]. In this study, not receiving definitive therapy for the patient’s cancer, with the exception of cancer of the prostate, was associated with a threefold greater death rate. Inadequate treatment remained a significant factor even after controlling for stage at diagnosis, socioeconomic factors, comorbidity, and physical functioning. Thus, withholding appropriate treatment because of age will result in inferior cancer survival in the elderly.
Traditionally, surgical procedures in particular have been viewed as carrying prohibitive risk in elderly patients. As the population ages, there has been an increased interest in the feasibility and outcome of surgical intervention in the elderly. In fact, the number of articles available upon performing a search for “neoplasm, surgery, and elderly” in Pubmed has greatly increased in number since 1990 (Fig.1). Over the past 30 years, numerous publications have shown that surgical procedures can be performed safely in the elderly [19, 54, 55, 59, 65, 83, 88, 103, 109, 117, 124]. The balance between operative risk and expected cure or palliation is important when treating any patient with cancer but even more so in the elderly. The impact of treatment on the quality of life is of prime importance. Many cancer operations are complex and require extensive dissection when attempted for cure in any patient population with significant morbidity and mortality associated with them regardless of the patient’s age.
Increases in surgical morbidity and mortality are associated with advanced disease states and emergency surgery. Since there is often a delay in cancer diagnosis in elderly patients, this can lead to more advanced cancers and a greater number of emergency presentations. Early diagnosis and treatment in the elderly should be encouraged.
This chapter reviews the role of surgery in the management of older patients with the following common solid organ cancers: (1) breast; (2) colorectal; (3) pancreatic; (4) hepatocellular; (5) gastric; (6) melanoma; and (7) esophageal. Preoperative assessment of the elderly cancer patient is also discussed.
2 Preoperative Assessment
As the population ages, the need to develop tools that assess the operative risk factors and predict postoperative outcome for patients with cancer has become of the utmost importance. The assessment of risk involves the interaction of the underlying physiological status, including normal physiological changes of aging, in addition to those changes attributable to comorbidity, cancer, surgery, and anesthesia. Advanced age should never be used as the sole criterion to deny standard curative therapy. Normal physiological changes occur with aging in every major organ system and affect the response to surgical procedures. The reductions in the functional reserve in each organ system represent parallel decreases in the capability to maintain homeostasis in the setting of surgical stress and anesthesia [118]. There is a decrease in the distensibility of the cardiac wall and a greater dependence on preload to increase cardiac output as patients get older. Renal function decreases with age, with a gradual loss of both renal mass and glomerular filtration rate. In the liver, there is a decrease in volume, blood flow, and perfusion with an increase in age. Pulmonary function changes with alterations in compliance and a decrease in the forced expiratory volume over one second and in vital capacity.
The ability to withstand the stress of various types of treatment for cancer is dependent on the functional reserve and ability to respond to the stress. However, no one tool exists currently for surgeons to assess functional reserve for all stages of management from preoperative to postoperative care. Until one is developed, the American Society of Anesthesiologists’ (ASA) general classification of Physical Status aids in determining patient risk assessment. The scale grades the mortality rate from anesthesia by assessing the physical state of the patient prior to anesthesia and surgery in order for the patient to be assigned to one of five groups.
The APACHE II system, which includes 12 variables including age and the presence or absence of severe chronic health problems, was originally devised to study patients in the intensive care unit. It is now used to study risk in the surgical setting. High APACHE II scores are associated with an increased morbidity and mortality for patients undergoing major elective surgery [56].
The Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) predicts both surgical morbidity and postoperative mortality in general surgery. It is similar to the APACHE score but includes EKG changes. This is advantageous, but the finding of chronic EKG changes, common in the older population, should not preclude them from definitive therapy [118]. The POSSUM data are mostly useful for the immediate postoperative period.
The Preoperative Assessment of Cancer in the Elderly score (PACE) is a questionnaire that provides a scoring method to evaluate the geriatric patient for candidacy for surgery. In a pilot study, it has been shown to be feasible, inexpensive, and rarely refused by patients [11], yet definitive results are still pending. PACE incorporates various tools to predict the outcome of cancer surgery in the elderly. The patient’s performance status and instrumental activities of daily living (IADL) correlated to prolonged hospital stay. The performance status is significantly lower in patients who developed morbidities, while the IADL score helped predict postoperative complications. Comorbidities did not play a role in predicting poor surgical outcome. PACE is aimed at overcoming the selection bias associated with advanced age as well as assisting the surgeon’s decision making for treatment.
Being able to assess risk preoperatively can help get the patient into the best presurgical state possible. Patients should be instructed and aided with smoking cessation, their respiratory function should be optimized with preoperative pulmonary toilet, and ways to optimize nutrition should be implemented. Also, optimizing preoperative medications such as beta-blockade should enhance cardiac function.
Abdominal cancer surgery often requires extensive dissection with possible large shifts in fluid balance. These conditions are particularly stressful for the very elderly because of decreased cardiac compliance. Intraoperative monitoring with central venous access, placement of an arterial line for continuous monitoring, and careful observation of urinary output all help to maintain a balanced cardiovascular state.
In addition to preoperative planning and intraoperative management in the elderly, there should also be optimum supervision of perioperative care by a multidisciplinary team. This team should aid in addressing those issues that contribute to morbidity and mortality in the elderly population such as pain, delirium, sepsis, poor nutrition, and rehabilitation. This team approach enables the elderly patient to obtain the full level of care that he or she, as well as all patients, require postoperatively to ensure better postoperative outcomes. Postoperative monitoring should include a telemetry unit in the early postoperative period (up to 72 hours) and close monitoring of fluid status to prevent under-resuscitation or fluid overload states. Nutritional support should be implemented as early as possible either enterally or parentally. Medications that can cause mental status changes should be avoided. Early mobilization with aggressive physical and occupational therapy is also needed in the elderly patient population.
3 Breast Cancer
The incidence of breast cancer rises with age. It is the most common cancer in women, with 182,460 cases predicted in 2008 [71] and the second leading cause of cancer deaths, with 40,480 in 2008 [71]. Nearly one third of breast cancers occur in women over the age of 70 years [115], and half the deaths are in women more than 65 years of age [170]. Despite this, many studies have demonstrated that breast self-examination, clinical examination by health-care providers, and screening mammography are underutilized in the elderly [89, 157, 166]. Also, many studies show significant undertreatment of the elderly in every stage of breast cancer.
A Swedish two-county trial confirmed that routine mammograms resulted in a reduction in breast cancer mortality for women between the ages of 50 and 74 years [143]. The relative risk was lower for women between the ages of 60 and 69 years (RR 0.6) than for women aged 70–74 years (RR 0.79). Thus, mammography should be performed routinely in the elderly, because the incidence of breast cancer continues to rise with age, and since the breasts become less dense with aging, the sensitivity of mammography should improve. In one series, the positive predictive value of an abnormal mammogram was greater for women over 65 years of age than for women 50–64 years old [49]. However, there may be as many as seven years of delay in seeing a benefit, which must be considered in relation to life expectancy.
There is a belief that breast cancers in the elderly may not be as aggressive as in younger women. The upper outer quadrant of the breast is still the most frequent site, and infiltrating ductal carcinoma is the most common histological type [5, 26]. In situ carcinomas do tend to be less common in the elderly [167]. Yet, in the past, this may have reflected an underutilization of mammography, since the overall incidence of in situ disease has increased dramatically in the last 20 years with the advent of routine mammography [45]. The elderly do have a higher incidence of estrogen receptor (ER)-positive and progesterone receptor (PR)-positive tumors [26, 136]. In one large series of over 10,000 women, 63% younger than the age of 50 years had ER-positive tumors, whereas 83% of those older than 50 years had ER-positive tumors [122]. In another series, which included 307,115 patients with invasive breast cancer, ER-positive tumors were seen in 87-91% of patients 65 years or older, while those younger than 65 years had ER-positive tumors 83% of the time [38, 99]. Progesterone receptor-positive tumors were also noted to be more common in the elderly patients in this series [38].
One of the greatest areas of controversy is whether breast cancer in the elderly should be managed any differently than in younger women. The fear of treatment morbidity and mortality sometimes prompts a minimalist approach in the elderly, whereas at other times, mastectomy is offered with little, if any, discussion about the possible desire for breast conservation. Likewise, reconstruction is often not readily offered to elderly patients. Randomized trials in both the United States and Europe have shown breast-conserving therapy (BCT) to be equivalent to mastectomy in terms of survival from early-stage breast cancer [5, 45, 167]. The National Institutes of Health consensus conference also found it to be the preferable method of treating early-stage disease [1]. More recently, a 20-year follow-up of the randomized study evaluating breast conservative surgery confirmed earlier findings of no decrease in disease-free or overall survival with breast-conserving surgery [51]. However, breast-conserving therapy is still underutilized for all ages and particularly in the elderly.
Hurria et al. [69] performed a retrospective study examining the factors influencing treatment patterns for women aged 75 and older with breast cancer. The goal of the study was to determine local and systemic treatment patterns for these patients. Even in this advanced-age cohort, there was a difference in treatment seen between those patients aged 75–79 and those who were older. The older patients were less likely to be offered an axillary dissection and radiation therapy compared to the younger group. Likewise, patients with increased comorbidities were significantly less likely to receive radiation therapy despite the findings of the CALGB study that radiation is beneficial, at a median follow-up of 7.9 years, in preventing locoregional disease in women aged 70 and older who have undergone partial mastectomy [67].
The study by Hurria also demonstrated that age was the greatest predictor of lesser treatment. However, there was no difference in receiving hormonal therapy, which is generally viewed as a “less” toxic treatment. Chemotherapy and axillary lymph node dissection, which are generally viewed as more “toxic” therapies, were less likely to be used in the armamentarium for patients aged 80 or older.
Other studies have also demonstrated that when breast conservation is performed, it is often done without axillary dissection or the use of postoperative radiation, as would be the standard for younger women [26, 162]. In one retrospective series, the survival of elderly women was found to be lower for those treated with less than standard procedures [162].
There are many factors that influence the use of BCT, including geographical location, race, and hospital characteristics. In one analysis of Medicare patients, geographical variations were marked in the use of BCT [111]. In another review of over 18,000 Caucasian women in three age groups—younger than 65, 65–74, and older than 74 years—the lowest rate of breast-conserving surgery was in the 65- to 74-year age group [48]. In areas of the country where BCT was common in the younger ages, it was less common in the older age group, whereas in areas where it was not commonly used in the younger group, it was more commonly used in the older group. It was postulated that disfiguring surgery was avoided in the younger group, whereas morbidity and mortality were avoided in the older group. But the morbidity and mortality for breast surgery in the elderly are very low [26]. The elderly have also been found to have a lower rate of BCT in the treatment of ductal carcinoma in situ (DCIS) [45].
With the advent of sentinel lymph node (SLN) biopsy, the fear of morbidity from an axillary dissection is decreased. SLN biopsy has been shown to be a safe procedure, with accuracies of 97% in randomized studies [84, 155]. Furthermore, the safety and feasibility have also been evaluated in the elderly [57]. In a series of 241 patients 70 years or older, the SLN was identified in all patients, with no major complications [57]. In this series, the SLN was positive for metastasis in 37% of the patients. Using the SLN technique obviates further axillary dissection in SLN-negative patients, therefore decreasing the bias of adequate staging in the elderly. In another study [66] of 104 patients between the ages of 65–95 (median 74), 29 (28%) patients had metastatic disease in at least one sentinel node. This resulted in nonsurgical treatment modification in 38% of patients. This finding has been shown in multiple other articles [39, 100]. McMahon et al. studied 730 breast cancer SLN mapping patients, 261 (36%) of whom were at least 70 years of age [100]. The overall sentinel node identification rate is statistically equivalent in the group under 70 (98.8%) versus the older group (97.1%). When controlling for primary tumor size and receptor status, the detection of SLN metastases still resulted in significantly higher rates of systemic therapy administration. Sentinel node biopsy should be offered to all women diagnosed with invasive breast cancer without palpable axillary disease regardless of age. Lumpectomy with SLN biopsy, which is now considered the standard of care, can be done as an outpatient procedure with intravenous sedation and local anesthesia with limited, if any, morbidity. This is the ideal situation for the elderly population, and there should be no reason they should be denied this definitive treatment.
Axillary dissections are primarily done for local control of disease in the setting when there is a positive sentinel node. The value in preventing distant disease is more controversial, and the procedure does carry risks, such as lymphedema. But in the past, axillary dissections were often omitted in the elderly patient [36]. Even when node dissections are performed, fewer nodes are removed in the elderly [33]. The risk for the development of local recurrence in the axilla is another consideration. In the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 trial, 18% of women with clinically negative axillae who did not have an axillary dissection went on to develop delayed axillary disease [52].
Radiation therapy to the breast after BCT for invasive cancer is considered standard therapy. Yet radiation is omitted in many elderly patients. In one series, even in areas where BCT was used frequently, only 41% of women over the age of 75 years had radiation, in contrast to 90% of women younger than 65 years and 86% of women between the ages of 65 and 74 years [48]. In another report, when surgical therapy was more aggressive and included axillary dissection in the elderly, the use of radiation was also more frequent [26]. Concerns have been expressed about whether the elderly will tolerate radiation, whether they will have difficulty completing therapy because of physical restraints in getting to radiation facilities, and whether long-term outcomes are the same as in younger patients. However, studies have provided evidence to refute these concerns [119, 142].
Disturbingly, local recurrence rates for breast cancer have been reported as high as 35% in the elderly when radiation is not given [125]. A randomized study from the CALGB compared 647 women over the age of 70 with stage I estrogen-positive breast cancer that were randomized to receive either lumpectomy plus tamoxifen or lumpectomy followed by tamoxifen and radiation therapy. The group given radiation had a significantly lower risk of locoregional recurrence (1% vs. 7%; p < 0.001) at a median follow-up of 7.9 years [67].
A recent advance in the treatment of breast cancer with radiation has been the addition of accelerated partial breast irradiation (APBI) such as MammoSite. In a study of 1,440 patients, 1,255 of whom had invasive breast cancer, treated with APBI, 23 patients developed an ipsilateral breast tumor recurrence with a median follow-up of 30.1 months [156]. Cosmetic results were considered good to excellent in 94% of patients at two-year follow-up. This treatment might be especially beneficial to elderly patients since the full treatment can be accomplished in five days as opposed to the five to six weeks required for standard radiation therapy.
In the elderly patient who undergoes a modified radical mastectomy, very rarely is breast reconstruction performed or even offered. In one study, the single greatest predictor for a surgeon to recommend breast reconstruction was age under 50 [104]. Yet experience with breast reconstruction in patients older than 60 demonstrates that it is safe, provides good long-standing results, and has acceptable complication rates when compared to younger patients. Age alone should not be a determining factor in selecting women for breast reconstruction.
For the few elderly women with breast cancer who have significant coexisting medical problems that preclude any form of surgical therapy and who have a limited life expectancy, it is not unreasonable to treat patients with hormonal therapy alone. Two prospective randomized trials compared tamoxifen alone to surgery and found good initial response rates for tamoxifen, although local control rates were worse than with surgery [16, 125].
Breast cancer treatment in the elderly should not be different from that in the younger groups. Breast-conserving surgery has been shown to be safe and effective in treating breast cancer with low morbidity and mortality. Sentinel node biopsy may eliminate the need for axillary node dissection in a number of elderly patients. Pharmacotherapy has improved, side effects have been reduced, and the rate of breast cancer in patients at risk has continued to decrease. All these modalities decrease morbidity and are just as applicable to the elderly as they are to the younger patient with breast cancer.
4 Colorectal Cancer
Colorectal cancer ranks third in the incidence of all cancers in both men and women. Over 148,810 cases of colorectal cancer were estimated in 2008, with 49,960 expected deaths [71]. The incidence of colorectal cancer increases with age, with 90% of patients being diagnosed after age 55 [145]. The probability of a male aged 70 or older developing colorectal cancer is 1 in 21 (4.8%), and for a female in the same age group, it is 1 in 23 (4.3%). This is a three- to fourfold increase compared to a person aged 60–69 [71]. Right-sided colon cancer is two times more common in elderly patients compared to younger cohorts (33% vs. 16%, respectively), which may account for the later presentation seen in the elderly [10].
Symptoms at presentation are reported to be similar in elderly compared to younger patients [76]. The tumor location in some studies was not significantly different for younger versus older patients [8], but in several other reports there was a difference, with more right-sided lesions and fewer rectal lesions [18, 76, 77, 107]. Patients with right-sided lesions are more likely to present later due to fewer signs and symptoms compared to left-sided or rectal cancers. Some studies showed that a higher percentage of women over age 70 were diagnosed with colorectal cancer compared to those under 67 [18, 145]. In a recent review by the United Kingdom National Bowel Cancer Project examining the epidemiology and surgical risk of colorectal cancer in the elderly, there was a significant decrease in the number of patients above age 75 (81%) undergoing surgery compared to those younger than 75 (88%, p < 0.001) [145]. Elderly patients are also more likely to undergo emergency surgical procedures compared to younger populations. In one study from the British Colorectal Cancer Collaborative Group (CCCG), the incidence of undergoing an emergency operation statistically increased from 11% for patients younger than 65 to 29% (p < 0.0001) for those 85 or older [34]. The same study also revealed that even within the elderly population, there is a difference in both stage presentation and likelihood of undergoing curative surgery, with the “older-of-the-old” presenting with more advanced disease and less likely to undergo curative surgery. These findings have also been demonstrated in earlier studies [76].
Because of data from a number of studies that demonstrate improved survival when at least 12 lymph nodes are examined in resection specimens for colon cancer, this number is now considered the gold standard. Lymph node involvement is the most important prognostic factor in patients with nonmetastatic colon cancer. The importance of this as well as the adequacy of the number of lymph nodes removed in elderly patients were recently examined [18]. As age increased, the number of nodes removed decreased, which might reflect a lesser operation performed. The study revealed a benefit in resecting at least 12 lymph nodes irrespective of patient age.
Surgical resection of the colon or rectum remains the mainstay of curative therapy for colorectal cancer. It is required in many cases even in the presence of disseminated disease to avoid or treat the inevitable complications of obstruction and bleeding. A number of retrospective series have looked at the influence of advanced age on the risk of surgical resection of colorectal cancer [23, 53]. The risk of perioperative complications is generally reported to be higher in the elderly than in younger patients. In a meta-analysis, the cardiovascular complications were statistically significantly increased (p < 0.001) in one series from 0.8% in patients under 65 years old to 4% in patients over the age of 75 years [34]. Pneumonia and respiratory failure were seen in 5% of patients under 65 years of age compared to 15% in those at least age 85 (p < 0.001). Anastomotic leak rates in the meta-analysis were not statistically different in young versus elderly patients. This finding was also seen in a Veterans Affairs’ study of surgery for colorectal cancer in patients older than 80 [90] as well as in a study by Araujo [8], which revealed no difference in anastomotic leak rate with regard to patient age.
Heriot et al. [64] recently examined the postoperative mortality rate for 2,533 elderly (age 80 and older) patients diagnosed with colorectal cancer in the U.K. The 30-day overall mortality rate was 15.6%, but increased to 27.5% for those at least age 95. Multivariate analysis for this group of very elderly patients revealed the following independent risk factors for 30-day mortality: age; operative urgency; ASA grade; resection versus no resection; metastatic disease. In a recent review by Tan, 30-day mortality was significantly lower for patients under 75 (4%) compared to older (11%) patients. In a VA study comparing colorectal patients aged 80 and older with younger matched controls, the 30-day mortality rate was higher but not statistically significant (p = 0.10). The overall one-, three-, and five-year survival, however, was 71%, 48%, and 31%, respectively, compared to 92%, 79%, and 71% in the control group [90].
Emergency operations are clearly associated with an increased mortality rate [70]. Elderly patients presenting with malignant large-bowel obstructions are a high-risk cohort, with increased postoperative complications and mortality [64]. Mortality rates are also high for palliative operations such as creation of a colostomy [59, 64, 140]. For example, in a review by Heriot, approximately 25% of patients who underwent either a palliative stoma or a Hartmann procedure had a 30-day postoperative mortality. These procedures are often done as an emergency in an end-stage patient—two factors known to contribute to an increased risk [59, 140]. Patients presenting as emergencies also tend to have more advanced-stage disease [161]. With the increase in mortality associated with an emergency operation and advanced-stage disease, it seems advisable to intervene earlier on an elective basis to avoid problems such as bleeding, perforation, and obstruction.
The role for laparoscopic-assisted colon resection has been shown to have similar outcomes compared to open procedures in stage II and III disease. Less postoperative pain, better pulmonary function, and less stress response seem particularly pertinent to the elderly population, where there is the potential for increased risk of morbidity associated with an open colectomy. Eight studies in the literature have compared open to laparoscopic colectomy in the elderly population, and all have concluded that laparoscopic resection was a safe option in this cohort [31]. Chautard et al. studied 536 laparoscopic colorectal procedures performed by one surgeon in 506 patients from June 1997 to August 2006. Of the 506 patients, 75 were age 70 or older and were matched with 103 younger patients with regards to risk factors and procedure performed. Only 40% of the colectomies were performed for cancer, but these patients were matched with regard to tumor stage to their younger counterparts. Conversion to an open procedure was comparable in both groups, and there were no mortalities in either group. Morbidity was not significantly different in either group. Chautard concluded that laparoscopic colectomy could be safely performed in the elderly population with similar postoperative outcomes as seen in a younger patient cohort despite the higher incidence of cardiorespiratory comorbidities preoperatively, but the sample size over age 70 was small.
The quality of life, although more difficult to measure, is an important outcome for any planned treatment. Creating a stoma must be viewed with caution, as it may be difficult for some elderly patients to manage not only physically but also psychologically. One series examined the posthospital course of patients over 80 years old who underwent surgery for a gastrointestinal tumor [103]. Thirty-one percent of patients went home following surgery, 51% convalesced in a specialized home or medical recovery center, 10% went to a nursing home or specialized institution, and 4% required nursing assistance at home or went to a family member’s home. Overall, 83% eventually returned to their homes without any change in their social environment. Using a survey, a Canadian study also explored the impact of surgery for colorectal cancer on quality of life and functional status in the elderly population (above 80). Those elderly patients who were selected to undergo a surgical procedure had a quality of life preoperatively that was comparable to the younger control population. Also, survivors of over five years had a quality of life comparable to their preoperative level. Stoma care, however, was a greater concern in the elderly population [97].
In a retrospective review of 50,042 patients with stage III colon cancer, Greene et al. revealed that patients at least age 70 have a lower survival rate than younger patients in the same stage subset [60]. The reason for this inferior survival may have been the reduced use of adjuvant chemotherapy in this age group. In a recent study comparing patients aged 75 and older to those under 75, cancer-related survival was comparable despite an increase in operative mortality compared to the younger population [8]. A recent Swiss study investigating surgery for rectal cancer in patients aged 80 and older concluded that, whenever possible, treatment with curative intent be employed in patients with rectal cancer regardless of age. The five-year overall survival was 67%, yet the majority of deaths that occurred within five years after surgery were not related to the cancer [6]. Another series indicated that although the physical status and operative mortality were worse in the elderly undergoing surgery for colorectal cancer, for those elderly who were fit for surgery, who underwent curative resection, and who survived over 30 days, the five-year survival was as good as in younger patients by multivariate analysis [9, 77]. Age alone should not be a contraindication for colectomy, and whenever possible the full curative treatment including adjuvant chemotherapy should be utilized when indicated.
5 Liver Metastasis for Colorectal Cancer
The liver is the most common site of metastasis for colorectal cancer. Liver resection remains the optimal treatment for patients with three or fewer colorectal liver metastases. Liver resection can lead to a 21–48% five-year survival in selected patients [67, 131, 126, 152, 141, 113]. The safety for performing liver resections has greatly improved in recent years owing to improvements in techniques of resection and intraoperative and postoperative care. Liver resections are now being performed with mortality rates of less than 5% [40, 68, 113, 126, 141].
Liver resections can also be performed safely in elderly patients. A number of series have looked at morbidity and mortality rates for older individuals. Fong et al. reviewed liver resections for colorectal metastases in 128 patients over 70 years old [54]. For patients over 70 years old, the perioperative mortality rate and the morbidity rate were the same as for patients younger than age 70. Most of the complications in the elderly were cardiopulmonary. In a multivariate analysis, three factors were found to be important in predicting complications. These were male sex, resection of at least one lobe of the liver, and an operating time of greater than four hours. The median hospital stay for patients aged 70 years and older was only one day longer than for patients less than 70 years old.
In a series of 61 patients older than 70 years, the morbidity was 41% and the mortality was 0% for first-time resections. The mortality increased for a repeat liver resection up to 7% [173]. Factors associated with poor long-term survival in a multivariate analysis were extrahepatic disease, high CEA level (> 200), and the presence of at least three liver lesions. The five-year survival rate of 36% was similar to those of younger patients after the first liver resection for patients without the presence of risk factors.
A recent Japanese study looked at 212 consecutive patients who underwent hepatic resection of colorectal liver metastases. The patients were divided into two groups: age 70 and older versus those under 70. The older patients (age 70 and older) were more likely to have severe cardiopulmonary disease and respiratory insufficiency. Similar rates of postoperative complications and mortality rates (0% in the elderly group vs. 0.49% in the younger group) were seen. The authors concluded that age should not be regarded as a medical contraindication for surgery in this setting [25].
These findings were also seen in a recent Italian review. The study compared surgical treatment of colorectal liver metastases in patients aged 70 and older versus those under 70. There was no statistical difference in overall morbidity, in-hospital mortality, or five-year survival. This group likewise concluded that age alone should not be a contraindication to surgery [98].
Long-term survival following liver resection for colorectal metastases is not influenced by age. No statistically significant difference in survival was found between elderly patients or younger patients in multiple reports [130]. Thus, an elderly patient with colorectal metastatic disease limited to the liver should do the same after liver resection as a younger patient unless he or she has prohibitive comorbidities.
6 Hepatocellular Cancer
In the United States, liver and intrahepatic bile duct cancer accounted for an estimated 21,370 cases in 2008 [71], with an estimated 18,410 deaths. Hepatic resection is the treatment of choice for patients with hepatocellular cancer (HCC) who do not have advanced cirrhosis. Treatment with major liver resections has resulted in a substantial decrease in mortality over the past 30 years, from 20% in the 1970s to less than 5% today [4]. This is due to a better understanding of liver anatomy and improved techniques for surgical resection. This has also led to a broadening of the indications for hepatic resection.
The extensive experience with resection of colorectal liver metastases demonstrates that liver resections can be performed safely in the elderly. Many patients with HCC, unlike those with metastatic colorectal cancer, have underlying cirrhosis, making surgical resection more challenging and dangerous. The functional reserve problems that are encountered with liver resection in the elderly are compounded by the presence of cirrhosis.
Comparative studies of the outcome of hepatic resection for HCC in the elderly versus the young patient are infrequent in the English literature [4] (Table 1). Many of these have been included in larger studies of hepatic resections for a wide multitude of reasons ranging from benign disease to HCC to colorectal metastasis.
The morbidity and mortality associated with resection for hepatocellular carcinoma in the elderly have been comparable when compared to the younger cohort of patients [41, 62, 144] (Table 1). With the exception of one series, the mortality rates are similar to those for younger patients [169]. In one study of 103 elderly patients, 70 years or older, with hepatocellular carcinoma, the resectability rate was 84% in the elderly, compared to 88% in the younger group [62]. The morbidity and mortality were comparable between the elderly and younger patients, 28.2% vs. 23.3 % and 9.7% vs. 6.0%, respectively. In the Milan study, the surgical complication rate for patients older than 75 undergoing resection for HCC was 0% compared to 38.5% in younger patients (p = 0.005) [4]. The median stay in the older patients was 7.5 days, which was less than the younger patients’ median stay of 9 days (p = 0.18).
The presence and severity of cirrhosis as judged by Child’s criteria influence the rate of operative morbidity and mortality. Regardless of their age, patients with advanced cirrhosis may not be candidates for major hepatic resection [41, 62, 109].
The overall five-year survival has been reported to be comparable with the younger patients’, ranging from 24.3 to 60% [62]. Hepatic resection for HCC is safe to perform in elderly patients as long as it is preceded by an accurate selection, including a significant workup of cardiopulmonary disease as discussed earlier.
7 Pancreatic Cancer
Over two thirds of patients with pancreatic cancer are over the age of 65 years at diagnosis [112, 3, 135]. In the United States, pancreatic cancer accounted for an estimated 37,680 cases in 2008 [71], with an estimated 34,290 deaths, making it the fourth most common cause of cancer-related deaths. The overall survival of patients with pancreatic cancer is dismal, with a five-year survival of 5%, up from 3% in 1986 [71]. This is attributed in part to the fact that the majority of patients with pancreatic cancer are diagnosed late in the course of the disease, when surgical resection is no longer feasible, as only 9–15% of patients are amenable to surgical resection [112, 135]. Also, there remains a bias against surgery for pancreatic cancer, so that even potentially surgically curable patients may not be referred to surgery. Even when resection is possible, the five-year survival is still only 20%.
A pancreaticoduodenectomy (PD), with or without sparing the pylorus, is the operation of choice for the most common lesions, which are located in the head of the pancreas. This is also the case for periampullary, duodenal, and distal common bile duct neoplasms. Until the early 1980s, pancreatic resection was associated with an extremely high complication rate and also a mortality rate as high as 26%. When weighed against the relatively small survival impact seen with successful surgery, many viewed the procedure as an unreasonable option for treatment [43, 35]. The role of this operation in elderly patients was fraught with even more concern due to the high morbidity and mortality risks. However, in more recent years, the morbidity and mortality rates associated with the Whipple operation have decreased significantly at specialty centers [27, 101, 160]. Mortality rates between 0-5% are more now the standard at high-volume centers [27, 101, 147]. In selected elderly patients, mortality rates for surgery are acceptable and even comparable to the younger group [54, 63, 93, 159]. The major causes of morbidity after pancreatic resection are related to complications associated with pancreatic fistula, anastomotic breakdown, and sepsis [83, 147, 160, 172].
One review of 138 patients over 70 years old who underwent pancreatic resection for malignancy reported an operative mortality rate of 6% and a morbidity rate of over 40% [54]. No significant differences were found in the length of hospital stay, the rate of intensive care unit admission, and morbidity or mortality rates between patients younger than 70 years old and those older than 70 years. A univariate analysis revealed that a history of cardiopulmonary disease, an abnormal preoperative electrocardiogram, or an abnormal chest radiograph were predictors of complications. However, the multivariate analysis found that the only factor that was a significant predictor of complications was a blood loss of more than 2 liters. The median survival was 18 months, and the five-year survival was 21%.
In an Italian study, 88 consecutive patients (70 patients with adenocarcinoma) who had a major pancreatic resection were evaluated in two groups: younger than 70 (53 patients), and at least 70 years old (35 patients) [28]. Survival and length of stay were not statistically different, but the presence of COPD was associated with a significantly higher mortality rate (30%, p = 0.018) compared to elderly patients without COPD (0%).
In another Italian study, 166 patients underwent curative PD for pancreatic adenocarcinoma over an 11-year period. The patients were divided into those older than 70 and those under 70. There was a trend (p = 0.09) toward a difference in the postoperative death rate between the two groups. This trend was related to the significantly higher operative mortality rate in elderly patients undergoing reoperation for surgical complications, mostly secondary to pancreatic-jejunal anastomotic leaks. Despite this, the pancreatic fistula rate and the overall complication rate were similar between the two groups [24].
Several other smaller series of pancreatic resections have also reported mortality rates in patients over 70 years old to be 5–14%, with morbidity rates of 14–48% ([37, 73, 139, 159].
The Johns Hopkins group has reported a series on 37 patients who were over the age of 70 years [27]. No significant differences were found between the length of stay and the rate of complications in patients over 70 years old compared to younger patients. However, the patients were admittedly carefully selected prior to the operation, as evidenced by no differences in the preoperative medical risk factors between patients under and over the age of 70 years. Another study from Hopkins evaluating the PD procedure in octogenarians showed that they had a longer postoperative length of stay and complication rate compared to younger patients. The mortality rate, however, was similar between the two groups [138].
Although long-term survival rates for resection are still low, they are not different in the elderly [101, 147]. One series reported a five-year survival rate for pancreatic cancer of 17% and 38% for periampullary tumors in patients over the age of 70 years and 19% for pancreatic cancer and 45% for periampullary tumors in patients younger than 70 years old [63]. The Hopkins group reported a five-year survival rate for pancreatic cancer of 19% in patients over the age of 80 years and 27% in patients under 80 years old (p value not significant) [138]. Despite limited long-term survival, resection remains superior to bypass or laparotomy alone. In a review of over 3,000 patients from the 1970s, mean survivals of 12.7 months for resection, 5.7 months for bypass, and 2.6 months for laparotomy alone were reported [164]. In the same review of over 2,000 patients from the 1980s, the mean survival increased significantly in resected patients to 17 months, whereas bypass (6.6 months) and laparotomy alone (3.1 months) were no different.
Still, the majority of patients with pancreatic cancer cannot be resected. In the past, surgery was needed in nearly 50% of patients for palliation of the two common complications that occur in the natural course of the disease, biliary and gastric obstruction [164]. Pain often also requires palliation. The mean survival of patients after bypass is considerably lower than for resection, at 4.0–11.3 months [164]. The operative mortality rate for biliary bypass ranges from 4–33%, with a mean of 19% [129]. The elderly may not tolerate bypass procedures as well as younger patients. A VA study did indicate a higher 30-day morbidity and mortality rate and a lower median survival rate after bypass procedures, which was statistically significant for patients over 70 years old [160]. However, VA patients may have unique characteristics that put them at higher risk. Each patient must be judged on an individual basis, taking into consideration the overall status of the patient and the expected benefit.
Currently, biliary obstruction can be effectively managed with stents placed either endoscopically or percutaneously transhepatically, as shown in several randomized series [7, 22, 42, 134]. Mortality rates are lower for stent placement than for surgical bypass and hospital stays are shorter. Although early complication rates are lower, long-term complication rates such as recurrent jaundice and cholangitis are more common than with surgical bypass but are acceptable in light of the high surgical morbidity and mortality for bypass procedures.
Gastric outlet obstruction, although a far less common presenting symptom, usually requires operative bypass for relief. The overall value of this procedure may be questioned because survival after bypass is often limited and does not always result in palliation [165]. More recently, endoscopically placed stents have been utilized as a surgical alternative.
8 Gastric Cancer
Gastric cancer rates have been declining over the past 75 years in the United States [78], but the prognosis has not improved, with five-year survival being 20–40% [121]. There were an estimated approximately 21,500 new cases in the United States in 2008 and 10,880 deaths [78]. Most of these were adenocarcinomas (86%), with 9% gastric lymphomas and 5% GIST/neuroendocrine tumors. Despite the fact that the incidence of the disease has fallen in the past 75 years, the number of patients diagnosed at or above age 75 is actually increasing [121]. Gastric cancer is generally seen in the elderly, with nearly 50% of males diagnosed with gastric cancer in the United States and 60% of females over the age of 70 years [175]. Surgery is the only curative modality currently available for gastric cancer, and in noncurative situations, palliative surgery is often needed for bleeding and obstruction. Surgery is the most powerful tool to improve prognosis, but the problem is the delay in diagnosis that leads to advanced disease at the time of exploration.
In Asia, where gastric cancer is much more common, many investigators have examined the characteristics of gastric cancer in the elderly. Symptoms at presentation and the location of disease in the stomach are similar in younger and older patients [15, 81]. One series reports no difference in histological type, whereas another reports a higher incidence of intestinal-type histology in the elderly [15, 81, 168]. The macroscopic pattern according to the Borrman criteria appears to be more localized in the elderly, but the occurrence of synchronous multiple primaries is greater and ranges from 7.7-13.2% [15, 81, 95]. The incidence of angiolymphatic invasion has been reported to be higher in the elderly. Two Japanese studies showed no difference with age in the incidence of lymph node metastases and stage at diagnosis, and 60% of all patients treated had T3 and T4 disease at the time of exploration [15, 81].
Curative surgery for gastric cancer requires either subtotal or total gastrectomy depending on the location of the tumor. The exact extent of lymph node dissection necessary remains a controversial subject. The removal of perigastric nodes is termed a Dl resection, whereas the removal of more extensive regional lymph nodes outside the perigastric region is termed a D2 resection. There is no agreement about whether to perform a D1 or D2 resection, especially when comparing the Western versus Asian literature. In the Western literature, studies have not shown a benefit to a more extensive lymph node dissection and have shown higher complication rates after D2 regional node dissections [21]. In a large prospective randomized trial from the Netherlands, with an average patient age in the mid-60s, the rate of surgical complications was doubled after D2 resections [21]. The rate of nonsurgical complications (with the exception of pulmonary complications, which were also doubled in the D2 group) such as cardiac, urinary tract, and thromboembolic was similar in both groups.
There have been a number of reports on the morbidity and mortality rates of gastric resections in the elderly (Table 2). Although preoperative risk factors are increased in the elderly with gastric cancer, particularly of a cardiac and pulmonary nature, the majority of complications and deaths are caused by infections, anastomotic leaks, and pulmonary problems, which are the same as in younger patients [19, 21, 116].
A recent Italian study reviewing 1,118 gastric resections for gastric cancer over a 15-year period had similar findings to that of the Japanese study. The study revealed that the overall postoperative surgical complication rate was 20% in the elderly group (age 75 and above) versus 17% in the younger. The postoperative mortality rate for both groups was 3%. Multivariate analysis revealed that age was not a risk factor for either postoperative morbidity or mortality [114].
The role of laparoscopy for gastric cancer has increased greatly over the past decade. Mochiki and colleagues investigated the role of laparoscopic-assisted gastrectomy for early gastric cancer in elderly (greater than age 70) patients in Japan. Early gastric cancer is more common in Japan due to increased surveillance since the disease is more prevalent than in Western countries. Blood loss was significantly less in the elderly than in the younger patient population. Operating time was the same in both groups, and there was no difference in postoperative complication rate or mortality [102]. They concluded that laparoscopic-assisted distal gastrectomy is safe in the elderly patient population, but the long-term survivals have not been studied in a comparative fashion.
An important element in deciding about surgical treatment in the elderly is the impact on the quality of life. In a small series of patients over the age of 70 years undergoing total gastrectomy, 70% of patients returned to “normal life” after one year, although the regaining of body weight was slower than in younger patients [82].
The five-year survival for curatively resected patients with gastric cancer is similar for younger and older patients (Table 3). In a recent Japanese study, the overall survival was significantly different between the two groups (p < 0.0001), but the cause-specific survival was not statistically different (p = 0.3447) [86]. A U.S. study found that the five-year survival was 17% for elderly patients (>70) compared to 21% for younger patients (p = 0.45). Surgical resection for gastric cancer should be offered to patients irrespective of age, as this offers the only chance for cure.
A smaller percentage of patients with gastric neoplasms are diagnosed with gastric lymphoma, which, like gastric adenocarcinoma, is a disease of the elderly. The treatment has changed greatly in the past 20 years from surgical to medical management. This shift toward medical management of this problem was due to the significant morbidity and mortality associated with the operative interventions in this setting. Today patients with mucosal-associated lymphoid tissue (MALT) lymphomas are treated with a “triple therapy” consisting of antibiotics. More advanced lymphomas may require chemotherapy and radiation. Surgery is now reserved for the patients with obstruction or bleeding who cannot be treated with these nonsurgical modalities.
9 Melanoma
The overall incidence of melanoma in the United States is increasing, and surgery continues to be the mainstay of therapy. In 2008, 62,480 new cases of cutaneous melanoma were expected, with estimated deaths of 11,200 [71]. The cumulative lifetime risk of developing melanoma in the United States in 1980 was 1/250, compared to 1/68 in 2002 [91]. The incidence of melanoma in the older population is increasing, while the incidence in the younger populations appears to be leveling off or even declining [30]. In 1985, 21.2% of cases occurred in patients over 70 years of age [149], and in 1990, this number increased to 27.2% of cases. Nearly 50% of all melanoma deaths in the United States are in white men older than age 50 [30]. Many studies have shown that men diagnosed with melanoma have a worse prognosis than women. However, in one study with over 12,000 patients, a multivariate analysis showed age to be independently important in the prognosis, especially in women [75].
The characteristics of melanoma appear to be slightly different in the elderly. Although the extremities are the most common location for melanomas in females, head and neck melanomas become more frequent with advancing age [146, 75]. In men, truncal melanomas are most common, but again head and neck melanomas become more frequent and surpass truncal melanomas after the age of 70 [146, 75]. Older patients have been reported to have worse prognostic indicators, with an increased incidence of ulceration, thicker melanomas, and deeper levels of invasion [12, 96, 108]. A study of more than 17,000 patients showed that for each 10-year increase in age, there was a decrease in both the 5- and 10-year survival rates [13]. This was corroborated in another study of 488 patients with nonmetastatic melanoma, where the 10-year survival rate was 84% for patients younger than 60 compared to 57% for those 60 or older [132]. Whether this represents a delay in the diagnosis or a worse malignant potential of these lesions in the elderly population is unknown.
The treatment for malignant melanoma is surgical excision with adequate margins; there is no evidence to suggest that the treatment for the elderly should be any different. Controversies over the width of margins and the need for regional lymph node dissection have been addressed in a number of randomized trials. These studies have shown that the necessary width of margins of resection is determined by the thickness of the primary melanoma. For lesions less than 1 mm thick, a 1-cm margin is adequate [153, 154]. For lesions greater than 1 mm thick, a margin of 2 cm is advised based on the results of the Intergroup Melanoma Surgery Trial [14, 74].
Although age has not been used as a criterion for determining the margins of resection, one large retrospective series did report age to be a significant independent factor in the risk for local recurrence [150]. Patients over 60 years old were found to have a local recurrence rate of 7.8%, patients between the ages of 30–59 had a local recurrence rate of 2.5%, and patients under 30 years old had a local recurrence rate of 1.2% at a median follow-up of eight years. Another study reported a 12.1% local recurrence rate for patients over the age of 70 with thin melanomas (<0.76 mm) [137]. Although an analysis was not performed for potential factors affecting this high recurrence rate, it might be explained by the higher incidence of head and neck melanomas in the elderly, with its attendant higher rate of local recurrence. In the prospective randomized trial evaluating margins, no difference was found in the rate of local recurrence for age over 50 years old versus under 50 years old [74]. However, a higher rate of local recurrence was demonstrated for head and neck lesions.
The dissection of regional lymph nodes for melanoma treatment is routine for patients with clinically positive nodes; however, the value of elective node dissection (ELND) for patients with clinically negative lymph nodes has long been debated. Since regional node dissections carry significant long-term complications, it would be advantageous to avoid them in patients with known negative lymph nodes. The use of the sentinel lymph node (SLN) biopsy technique, introduced by Morton in 1992, has allowed an accurate evaluation of the lymph node basin without a complete dissection. However, complete dissections are still necessary for positive sentinel nodes and for palpable nodal disease. Patients are now routinely getting SLN biopsies for any lesion greater than 1 mm in thickness.
SLN biopsies can be done using one of two techniques or combining both. The original technique used a blue dye injected intradermally at the site of the primary melanoma. The regional node basin was then explored surgically for the identification of a “blue node,” which was removed. These were termed the sentinel lymph nodes. If these nodes were positive for tumor on permanent section, then a full node dissection would be performed at a separate time. If negative, then no dissection was done. Initial experience with this technique showed the blue dye method was able to identify the sentinel lymph node in 82% of patients [105]. The false-negative rate of the technique in identifying the presence of metastatic disease was 1% [105]. Because of technical difficulties with the blue dye, radiolymphoscintigraphy using technetium-labeled sulfur colloid has been utilized to locate the sentinel node [85]. Utilizing both techniques has allowed the sentinel node to now be harvested with 98% accuracy [92].
Morton [106] reported the findings of 1,269 patients with intermediate-thickness melanomas (1.2–3.5 mm) randomly assigned to wide local excision with or without SLN biopsy. As expected, disease-free survival was significantly higher (p = 0.009) in the patients undergoing SLN biopsy compared to the observation group at five years since potentially positive lymph nodes were not removed from this group. The overall rate of death from melanoma and melanoma-specific survival, however, was similar for both groups, but for patients with positive nodal metastasis, the five-year survival rate was higher in the SLN group (72% vs. 52%). Also, the number of positive lymph nodes was lower in the SLN group (1.4 vs. 3.3), showing disease progression during observation. This study led to the conclusion that SLN biopsy has staging, prognostic, and survival value in patients with intermediate-thickness melanoma.
Adjuvant therapy for stage III melanoma remains controversial. High-dose interferon alfa-2b was approved by the U.S. Food and Drug Administration for adjuvant therapy of high-risk melanoma (stage IIb and III) in 1995 [78, 80] but is highly toxic. A pooled analysis of adjuvant high dose interferon trials showed a benefit in relapse free survival but not overall survival [79]. Currently, patients with high-risk melanoma should be offered interferon therapy or enrollment in a clinical trial.
In a large retrospective analysis of the national cancer database for melanoma (comprising a total of 84,836 cases), factors associated with decreased survival included more advanced stage at diagnosis, nodular or acral lentiginous histology, increased age, male gender, nonwhite race, and lower income. Five-year survival was worse stage for stage in patients 60 years or older. For early disease, the five-year survival was 81.4% for patients older than 60 versus 90.5% for those under 60 years. For late disease, the five-year survival was 32% for the older patients versus 40.5% for the younger ones [29].
Because surgical treatment of melanoma can be done with low risk, in fact under local anesthesia if necessary, no one should be denied it because of age or poor performance status. Treatment of melanoma for elderly patients should be as aggressive as in younger patients.
10 Esophageal Cancer
The incidence of esophageal cancer is rising in the United States, with an estimated 16,470 Americans diagnosed in 2008 versus 13,100 in 2002 [71, 72]. Most of this increase is associated with an increase in the number of cases of adenocarcinoma. The death rate remains high, with 14,280 deaths in 2008 versus 12,600 in 2002 [71, 72]. Most cases (79%) are diagnosed in men between the fifth and seventh decades of life. The five-year survival rate has tripled from 6% in the mid-1970s to 18% as of 2003 [71].
Although controversies exist on the treatment for primary esophageal cancer, with the increase in adenocarcinoma and distal esophageal lesions, surgery has become more common as a first-line therapy. Morbidity and mortality for esophagectomy have improved but are still significant. Some reports state that mortality rates are strongly related to age and preoperative performance status [121, 2, 50]. In more recent reports, morbidity and mortality rates are similar for elderly and younger patients mostly as a result of advances in perioperative management [20, 44, 123].
An Italian group studied the effects of advanced age on the outcomes from esophagectomy for esophageal cancer at a high-volume center [127]. The patients, who underwent surgery between 1992 and 2005, were divided between those under 70 (580 patients) and those 70 and above (159 patients). All patients underwent a laparotomy with a right thoracotomy, with some patients requiring a left cervical incision for a tumor in the upper third of the esophagus. Preoperative cardiac and pulmonary risk factors were more common in the elderly group. The 30-day mortality rate and overall morbidity rate were the same for both groups, at 1.9% and 49%, respectively. The overall five-year survival rate was 33.6% for the younger patients and 35.4% for the older group (p = 0.257). In the elderly, survival rates were the same for patients aged 70–74 versus those who were older.
A recent report from China showed similar findings when comparing esophagectomy for esophageal cancer in elderly patients versus younger ones. Again, the elderly population was more likely to have comorbid conditions, including hypertension, respiratory dysfunction, and diabetes. The morbidity and mortality rates were similar in both groups despite the fact that cardiopulmonary complications were encountered more frequently in the elderly group [94].
These data support the use of esophagectomy in the elderly. It has been shown that esophagectomy can be performed safely in elderly patients even with comorbid conditions, and they can be expected to have equivalent long-term survival after a curative resection.
11 Conclusions
Surgical intervention in the elderly should no longer be ruled out simply because of the patient’s numerical age. Appropriate evaluation of the existing comorbidities and optimization are essential to successful surgical outcomes. Multiple studies have shown the safety and benefit of performing a vast range of oncologic surgeries in the elderly. As the population ages, more elderly patients will present with neoplasms, which will need surgical intervention. The data demonstrate that under optimized conditions, the elderly can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is deemed to be the appropriate therapy for the particular cancer, the elderly patient should not be denied this modality because of his or her age.
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Heimann, D.M., Kemeny, M.M. (2009). Surgical Management of the Older Patient with Cancer. In: Hurria, A., Balducci, L. (eds) Geriatric Oncology. Springer, Boston, MA. https://doi.org/10.1007/978-0-387-89070-8_8
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