A Surgeon’s Guide to Treating Older Patients With Colorectal Cancer

  • Sooyeon Kim
  • Simon C. Lee
  • Celette S. Skinner
  • Cynthia J. Brown
  • Courtney J. BalentineEmail author
Surgery and Surgical Innovations in Colorectal Cancer (S Huerta, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Surgery and Surgical Innovations in Colorectal Cancer


Purpose of Review

Review strategies to improve outcomes of colorectal cancer treatment in older patients.

Recent Findings

Older colorectal patients face many barriers to recovery during their initial inpatient stay following surgery and after leaving the hospital. In addition to the risk of inpatient morbidity and mortality, older patients are more likely to require post-acute care services to face nutritional deficits and to experience complications of chemoradiation.


In order to improve outcomes for older patients with colorectal cancer, it is important for surgeons to recognize their unique needs and to develop plans to address them. The involvement of a multi-disciplinary team with geriatric experience can guide planning for surgery, the immediate postoperative recovery, and long-term survivorship.


Colorectal cancer Older patients Perioperative strategies Post-acute care needs 



Simon C. Lee is supported by the National Cancer Institute (grant no. R01CA203856).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. 1.
    United States Census Bureau (2018) Methodology, assumptions, and inputs for the 2017 national population projections. Accessed 09/16/2018.Google Scholar
  2. 2.
    Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, et al. SEER cancer statistics review, 1975–2015, National Cancer Institute. Bethesda, MD,, based on November 2017 SEER data submission, posted to the SEER web site, 2018.
  3. 3.
    Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA Cancer J Clin. 2018;68(1):7–30.CrossRefGoogle Scholar
  4. 4.
    Haggar FA, Boushey RP. Colorectal cancer epidemiology: incidence, mortality, survival, and risk factors. Clin Colon Rectal Surg. 2009;22(4):191–7.CrossRefGoogle Scholar
  5. 5.
    Citarda F, Tomaselli G, Capocaccia R, Barcherini S, Crespi M, Italian Multicentre Study Group. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut. 2001;48:812–5.CrossRefGoogle Scholar
  6. 6.
    United States Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, Curry SJ, Davidson KW, Epling JW Jr, et al. Screening for colorectal cancer: US preventive services task force recommendation statement. JAMA. 2016;315(23):2564–75.CrossRefGoogle Scholar
  7. 7.
    National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology. Colon cancer version 3.2018. 2018 Aug 7; National Comprehensive Cancer Network.Google Scholar
  8. 8.
    Claassen YHM, Vermeer NCA, Iversen LH, van Eycken E, Guren MG, Mroczkowski P, et al. Treatment and survival of rectal cancer patients over the age of 80 years: a EURECCA international comparison. Br J Cancer. 2018;119:517–22. CrossRefGoogle Scholar
  9. 9.
    Alves A, Panis Y, Mathieu P, Mantion G, Kwiatkowski F, Slim K. Association Française de Chirurgie. Postoperative mortality and morbidity in French patients undergoing colorectal surgery results of a prospective multicenter study. Arch Surg. 2005;140(3):278–83.CrossRefGoogle Scholar
  10. 10.
    Kristjansson SR, Nesbakken A, Jordhøy MS, Skovlund E, Audisio RA, Johannessen HO, et al. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol. 2010;76(3):208–17.CrossRefGoogle Scholar
  11. 11.
    Baré M, Mora L, Torà N, Gil MJ, Barrio I, Collera P, et al. CCR-CARESS score for predicting operative mortality in patients with colorectal cancer. Br J Surg. 2018;105:1853–61.CrossRefGoogle Scholar
  12. 12.
    Witlox J, Eurelings LM, de Jonghe JM, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA. 2010;304(4):443–51.CrossRefGoogle Scholar
  13. 13.
    Chen CC, Li HC, Liang JT, Lai IR, Purnomo JD, Yang YT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery: a cluster randomized clinical trial. JAMA Surgery. 2017;152(9):827–34.CrossRefGoogle Scholar
  14. 14.
    Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med. 1995;332(20):1338–44.CrossRefGoogle Scholar
  15. 15.
    Flood KL, Maclennan PA, McGrew D, Green D, Dodd C, Brown CJ. Effects of an acute care for elders unit on costs and 30-day readmissions. JAMA Intern Med. 2013;173(11):981–7.CrossRefGoogle Scholar
  16. 16.
    Bail K, Draper B, Berry H, Karmel R, Goss J. Predicting excess cost for older inpatients with clinical complexity: a retrospective cohort study examining cognition, comorbidities and complications. PLoS One. 2018;13(2):e0193319.CrossRefGoogle Scholar
  17. 17.
    Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51(4):451–8.CrossRefGoogle Scholar
  18. 18.
    Lawrence VA, Hazuda HP, Cornell JE, Pederson T, Bradshaw PT, Mulrow CD, et al. Functional independence after major abdominal surgery in the elderly. J Am Coll Surg. 2004;199(5):762–72.CrossRefGoogle Scholar
  19. 19.
    Artinyan A, Orcutt ST, Anaya DA, Richardson P, Chen GJ, Berger DH. Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients. Ann Surg. 2015;261(3):497–505.CrossRefGoogle Scholar
  20. 20.
    Tevis SE, Kohlnhofer BM, Stringfield S, Foley EF, Harms BA, Heise CP, et al. Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival. Dis Colon Rectum. 2013;56(12):1339–48.CrossRefGoogle Scholar
  21. 21.
    Balentine CJ, Naik AD, Berger DH, Chen H, Anaya DA, Kennedy GD. Postacute care after major abdominal surgery in elderly patients: intersection of age, functional status, and postoperative complications. JAMA Surg. 2016;151(8):759–66.CrossRefGoogle Scholar
  22. 22.
    Bailey EA, Hoffman RL, Wirtalla C, Karakousis G, Kelz RR. Development and validation of a prediction model for patients discharged to post-acute care after colorectal cancer surgery. Surgery. 2017;161(4):1049–57.CrossRefGoogle Scholar
  23. 23.
    Sacks GD, Lawson EH, Dawes AJ, Gibbons MM, Zingmond DS, Ko CY. Which patients require more care after hospital discharge? An analysis of post-acute care use among elderly patients undergoing elective surgery. J Am Coll Surg. 2015;220(6):1113–1121.e2. Scholar
  24. 24.
    Balentine CJ, Mason MC, Richardson PJ, Kougias P, Bakaeen F, Naik AD, et al. Variation in postacute care utilization after complex surgery. J Surg Res. 2018;230:61–70. Scholar
  25. 25.
    •• Balentine CJ, Richardson PA, Mason MC, Naik AD, Berger DH, Anaya DA. Postacute care and recovery after cancer surgery: still a long way to go. Ann Surg. 2017;265(5):993–9 These papers highlight the fact that, in addition to the risk of inpatient morbidity and mortality, older colorectal patients face unique challenges, including increased use of post-acute care services and complications of chemoradiation.CrossRefGoogle Scholar
  26. 26.
    Gage B, Morley M, Smith L, Ingber MJ, Deutsch A, Kline T, et al. Post-acute care payment reform demonstration: final report. Centers for Medicare & Medicaid Services 2012. Accessed 10/28/2018.Google Scholar
  27. 27.
    Balentine CJ, Leverson G, Vanness DJ, Knight S, Turan J, Brown CJ, et al. Selecting post-acute care settings after abdominal surgery: are we getting it right? Am J Surg 2017.Google Scholar
  28. 28.
    Baier RR, Wysocki A, Gravenstein S, Cooper E, Mor V, Clark M. A qualitative study of choosing home health care after hospitalization: the unintended consequences of ‘patient choice’ requirements. J Gen Intern Med. 2015;30(5):634–40.CrossRefGoogle Scholar
  29. 29. Home health compare. Available at: Accessed 25 Aug 2018.
  30. 30.
    Bowles KH, Foust JB, Naylor MD. Hospital discharge referral decision making: a multidisciplinary perspective. Appl Nurs Res. 2003;16(3):134–43.CrossRefGoogle Scholar
  31. 31.
    Bowles KH, Hanlon A, Holland D, Potashnik SL, Topaz M. Impact of discharge planning decision support on time to readmission among older adult medical patients. Prof Case Manag. 2014;19(1):29–38.CrossRefGoogle Scholar
  32. 32.
    Bowles KH, Holmes JH, Ratcliffe SJ, Liberatore M, Nydick R, Naylor MD. Factors identified by experts to support decision making for post acute referral. Nurs Res. 2009;58(2):115–22.CrossRefGoogle Scholar
  33. 33.
    Bowles KH, McCorkle R, Nuamah IF. Homecare referrals and 12-week outcomes following surgery for cancer. Oncol Nurs Forum. 2008;35(3):377–83.CrossRefGoogle Scholar
  34. 34.
    Puts MT, Papoutsis A, Springall E, Tourangeau AE. A systematic review of unmet needs of newly diagnosed older cancer patients undergoing active cancer treatment. Support Care Cancer. 2012;20(7):1377–94.CrossRefGoogle Scholar
  35. 35.
    Stockwell-Smith MW, Marshall AP, Argo A, Brown L, Howe S, et al. Hospital discharge processes involving older adults living with dementia: an integrated literature review. J Clin Nurs. 2018;27(5–6):e712–25. Scholar
  36. 36.
    Hawkins NA, Pollack LA, Leadbetter S, Steele WR, Carroll J, Dolan JG, et al. Informational needs of patients and perceived adequacy of information available before and after treatment of cancer. J Psychosoc Oncol. 2008;26(2):1–16.CrossRefGoogle Scholar
  37. 37.
    Wong C, Hogan D. Care transitions: using narratives to assess continuity of care provided to older patients after hospital discharge. Can Geriatr J. 2016;19(3):97–102.Google Scholar
  38. 38.
    Samuelsson KS, Egenvall M, Klarin I, Lökk J, Gunnarsson U, Iwarzon M. The older patient’s experience of the healthcare chain and information when undergoing colorectal cancer surgery according to the enhanced recovery after surgery concept. J Clin Nurs. 2018;27(7–8):e1580–8. Scholar
  39. 39.
    Li L, Lau KS, Ramanathan V, Orcutt ST, Sansgiry S, Albo D, et al. Ileostomy creation in colorectal cancer surgery: risk of acute kidney injury and chronic kidney disease. J Surg Res. 2017;210:204–12. Scholar
  40. 40.
    Hooper L, Bunn D, Jimoh FO, Fairweather-Tait SJ. Water-loss dehydration and aging. Mech Ageing Dev. 2014;136-137:50–8. Scholar
  41. 41.
    Marshall KA, Burson R, Gall K, Saunders MM. Hospital admissions for malnutrition and dehydration in patients with dementia. Home Healthcare Now. 2016;34(1):32–7.CrossRefGoogle Scholar
  42. 42.
    de Oliveira AL, Boroni Moreira AP, Pereira Netto M, Gonçalves Leite IC. A cross-sectional study of nutritional status, diet, and dietary restrictions among persons with an ileostomy or colostomy. Ostomy Wound Manage. 2018;64(5):18–29.CrossRefGoogle Scholar
  43. 43.
    Landi F, Picca A, Calvani R, Marzetti E. Anorexia of aging: assessment and management. Clin Geriatr Med. 2017;33(3):315–23. Scholar
  44. 44.
    Locher JL, Robinson CO, Bailey FA, Carroll WR, Heimburger DC, Magnuson JS, et al. The contribution of social factors to undereating in older adults with cancer. J Support Oncol. 2009;7(5):168–73.Google Scholar
  45. 45.
    Buys DR, Roth DL, Ritchie CS, Sawyer P, Allman RM, Funkhouser EM. Nutritional risk and body mass index predict hospitalization, nursing home admissions, and mortality in community-dwelling older adults: results from the UAB study of aging with 8.5 years of follow-up. J Gerontol A Biol Sci Med Sci. 2014;69(9):1146–53. Scholar
  46. 46.
    Danielsen AK, Soerensen EE, Burcharth K, Rosenberg J. Learning to live with a permanent intestinal ostomy: impact on everyday life and educational needs. J Wound Ostomy Continence Nurs. 2013;40(4):407–12.CrossRefGoogle Scholar
  47. 47.
    David GG, Slavin JP, Willmott S, Corless DJ, Khan AU, Selvasekar CR. Loop ileostomy following anterior resection: is it really temporary? Color Dis. 2010;12:428–32.CrossRefGoogle Scholar
  48. 48.
    Optimal perioperative management of the geriatric patient: best practices guidelines from ACS NSQIP/American Geriatrics Society. Available at: programs/geriatric/acs. Accessed 12/18/2017.
  49. 49.
    Tejedor P, Pastor C, Gonzalez-Ayora S, Ortega-Lopez M, Guadalajara H, Garcia-Olmo D. Short-term outcomes and benefits of ERAS program in elderly patients undergoing colorectal surgery: a case-matched study compared to conventional care. Int J Color Dis. 2018;33(9):1251–8.CrossRefGoogle Scholar
  50. 50.
    Stone AB, Yuan CT, Rosen MA, Grant MC, Benishek LE, Hanahan E, et al. Barriers to and facilitators of implementing enhanced recovery pathways using an implementation framework: a systematic review. JAMA Surg. 2018;153(3):270–9. Scholar
  51. 51.
    Hinoi T, Kawaguchi Y, Hattori M, Okajima M, Ohdan H, Yamamoto S, et al. Laparoscopic versus open surgery for colorectal cancer in elderly patients: a multicenter matched case-control study. Ann Surg Oncol. 2015;22(6):2040–50.CrossRefGoogle Scholar
  52. 52.
    Shahir MA, Lemmens VE, van de Poll-Franse LV, Voogd AC, Martijn H, Janssen-Heijnen ML. 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(17):3015–21.CrossRefGoogle Scholar
  53. 53.
    •• Kenzik KM, Balentine C, Richman J, Kilgore M, Bhatia S, Williams GR. New-onset cardiovascular morbidity in older adults with stage I to III colorectal cancer. J Clin Oncol. 2018;36(6):609–16 These papers highlight the fact that, in addition to the risk of inpatient morbidity and mortality, older colorectal patients face unique challenges, including increased use of post-acute care services and complications of chemoradiation.CrossRefGoogle Scholar
  54. 54.
    Abraham A, Habermann EB, Rothenberger DA, Kwaan M, Weinberg AD, Parsons HM, et al. Adjuvant chemotherapy for stage III colon cancer in the oldest old: results beyond clinical guidelines. Cancer. 2013;119(2):395–403.CrossRefGoogle Scholar
  55. 55.
    van Erning FN, Bernards N, Creemers GJ, Vreugdenhil A, Lensen CJPA, Lemmens VEPP. Administration of adjuvant oxaliplatin to patients with stage III colon cancer is affected by age and hospital. Acta Oncol. 2014;53(7):975–80.CrossRefGoogle Scholar
  56. 56.
    Gagliardi G, Pucciarelli S, Asteria CR, Infantino A, Romano G, Cola B, et al. A nationwide audit of the use of radiotherapy for rectal cancer in Italy. Tech Coloproctol. 2010;14(3):229–35.CrossRefGoogle Scholar
  57. 57.
    Papamichael D, Audisio RA, Glimelius B, de Gramont A, Glynne-Jones R, Haller D, et al. Treatment of colorectal cancer in older patients: International Society of Geriatric Oncology (SIOG) consensus recommendations 2013. Ann Oncol. 2015;26(3):463–76.CrossRefGoogle Scholar
  58. 58.
    participants PACE, Audisio RA, Pope D, Ramesh HS, Gennari R, van Leeuwen BL, et al. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical ask force prospective study. Crit Rev Oncol Hematol. 2008;65(2):156–63.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Sooyeon Kim
    • 1
  • Simon C. Lee
    • 2
  • Celette S. Skinner
    • 2
  • Cynthia J. Brown
    • 3
    • 4
  • Courtney J. Balentine
    • 1
    • 5
    Email author
  1. 1.Department of SurgeryUniversity of Texas Southwestern Medical CenterDallasUSA
  2. 2.Department of Clinical Sciences, Harold C. Simmons Comprehensive Cancer CenterUniversity of Texas Southwestern Medical CenterDallasUSA
  3. 3.Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Care CenterUniversity of Alabama at BirminghamBirminghamUSA
  4. 4.Division of Gerontology, Geriatrics, and Palliative CareUniversity of Alabama at BirminghamBirminghamUSA
  5. 5.VA North Texas Health Care SystemDallasUSA

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