Surgical approach and geriatric evaluation for elderly patients with colorectal cancer

  • Marco Vacante
  • Erika Cristaldi
  • Francesco Basile
  • Antonio Maria BorzìEmail author
  • Antonio Biondi
Review Article


This review aims to define the most appropriate surgical approach and geriatric evaluation for elderly patients with colorectal cancer (CRC). Surgery represents the main treatment for CRC, but elderly cancer patients still represent a challenge for the surgeon due to frequent comorbidities such as cardiovascular and pulmonary diseases, which increase operative risk as well as the risk of postoperative morbidity and mortality. Cancer patients with comorbidities show lower survival rates and quality of life, together with higher healthcare costs. There is also evidence that patients with comorbidities sometimes receive modified treatment, compromising optimal care. To optimize treatment, the approach to elderly cancer patients needs a multidisciplinary team to assess preoperative conditions, prevent post-surgical complications and improve outcome, especially for frail patients. Laparoscopic surgery for CRC shows a number of advantages compared to conventional surgery such as less postoperative pain, rapid return to prior activities and a decrease in costs. Recent studies confirm that laparoscopic procedures could be performed safely on both older and younger patients with no difference compared with open surgery as regards morbidity or length of hospital stay.


Elderly Colorectal cancer Oncology Cancer surgery 



We wish to thank the Scientific Bureau of the University of Catania for language support.


No specific funding was obtained.

Compliance with ethical standards

Conflict of interest

The authors report no conflicts of interest.

Research involving human participants and/or animals

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

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Edwards BK, Ward E, Kohler BA et al (2010) Annual report to the nation on the status of cancer, 1975–2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates. Cancer 116:544–573. CrossRefGoogle Scholar
  2. 2.
    Balducci L (2014) Studying cancer treatment in the elderly patient population. Cancer Control 21:215–220. CrossRefGoogle Scholar
  3. 3.
    Siegel R, Naishadham D, Jemal A (2013) Cancer statistics, 2013. CA Cancer J Clin 63:11–30. CrossRefGoogle Scholar
  4. 4.
    Ugolini G, Ghignone F, Zattoni D et al (2014) Personalized surgical management of colorectal cancer in elderly population. World J Gastroenterol 20:3762–3777. CrossRefGoogle Scholar
  5. 5.
    Grosso G, Biondi A, Marventano S et al (2012) Major postoperative complications and survival for colon cancer elderly patients. BMC Surg 12(Suppl 1):S20. CrossRefGoogle Scholar
  6. 6.
    Geraghty J, Shawihdi M, Devonport E et al (2018) Reduced risk of emergency admission for colorectal cancer associated with the introduction of bowel cancer screening across England: a retrospective national cohort study. Colorectal Dis 20:94–104. CrossRefGoogle Scholar
  7. 7.
    Balducci L, Aapro M (2005) Epidemiology of cancer and aging. Cancer Treat Res 124:1–15CrossRefGoogle Scholar
  8. 8.
    Sehl M, Sawhney R, Naeim A (2005) Physiologic aspects of aging: impact on cancer management and decision making, part II. Cancer J 11:461–473CrossRefGoogle Scholar
  9. 9.
    Ng O, Watts E, Bull CA et al (2016) Colorectal cancer outcomes in patients aged over 85 years. Ann R Coll Surg Engl 98:216–221. CrossRefGoogle Scholar
  10. 10.
    Ugolini G, Pasini F, Ghignone F et al (2015) How to select elderly colorectal cancer patients for surgery: a pilot study in an Italian academic medical center. Cancer Biol Med 12:302–307. Google Scholar
  11. 11.
    Kowdley GC, Merchant N, Richardson JP et al (2012) Cancer surgery in the elderly. Sci World J 2012:303852. CrossRefGoogle Scholar
  12. 12.
    Kumar R, Jain K, Beeke C et al (2013) A population-based study of metastatic colorectal cancer in individuals aged ≥ 80 years: findings from the South Australian Clinical Registry for Metastatic Colorectal Cancer. Cancer 119:722–728. CrossRefGoogle Scholar
  13. 13.
    Borzì AM, Biondi A, Basile F et al (2018) Olive oil effects on colorectal cancer. Nutrients. Google Scholar
  14. 14.
    Uccello M, Malaguarnera G, Basile F et al (2012) Potential role of probiotics on colorectal cancer prevention. BMC Surg 12(Suppl 1):S35. CrossRefGoogle Scholar
  15. 15.
    Vacante M, D’Agata V, Motta M et al (2012) Centenarians and supercentenarians: a black swan. Emerging social, medical and surgical problems. BMC Surg 12(Suppl 1):S36. CrossRefGoogle Scholar
  16. 16.
    Malaguarnera G, Leggio F, Vacante M et al (2012) Probiotics in the gastrointestinal diseases of the elderly. J Nutr Health Aging 16:402–410CrossRefGoogle Scholar
  17. 17.
    Motta M, Cardillo E, Vacante M, Malaguarnera M (2010) Supercentenarians: the oldest people in the world. Indian J Med Res 131:4–6Google Scholar
  18. 18.
    Marventano S, Forjaz M, Grosso G et al (2013) Health related quality of life in colorectal cancer patients: state of the art. BMC Surg 13(Suppl 2):S15. CrossRefGoogle Scholar
  19. 19.
    Millan M, Merino S, Caro A et al (2015) Treatment of colorectal cancer in the elderly. World J Gastrointest Oncol 7:204–220. CrossRefGoogle Scholar
  20. 20.
    Ellis G, Gardner M, Tsiachristas A et al (2017) Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 9:CD006211. Google Scholar
  21. 21.
    Malaguarnera M, Vacante M, Frazzetto PM, Motta M (2013) What is the frailty in elderly? Value and significance of the multidimensional assessments. Arch Gerontol Geriatr 56:23–26. CrossRefGoogle Scholar
  22. 22.
    Kristjansson SR, Jordhøy MS, Nesbakken A et al (2010) Which elements of a comprehensive geriatric assessment (CGA) predict post-operative complications and early mortality after colorectal cancer surgery? J Geriatr Oncol 1:57–65. CrossRefGoogle Scholar
  23. 23.
    Lee YH, Oh H-K, Kim D-W et al (2016) Use of a Comprehensive geriatric assessment to predict short-term postoperative outcome in elderly patients with colorectal cancer. Ann Coloproctol 32:161–169. CrossRefGoogle Scholar
  24. 24.
    Balducci L (2006) Management of cancer in the elderly. Oncology (Williston Park, NY) 20:135–143 (discussion 144, 146, 151–152) Google Scholar
  25. 25.
    PACE participants, Audisio RA, Pope D et al (2008) Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol 65:156–163. CrossRefGoogle Scholar
  26. 26.
    Papamichael D, Audisio RA, Glimelius B et al (2015) Treatment of colorectal cancer in older patients: International Society of Geriatric Oncology (SIOG) consensus recommendations 2013. Ann Oncol 26:463–476. CrossRefGoogle Scholar
  27. 27.
    Savva GM, Donoghue OA, Horgan F et al (2013) Using timed up-and-go to identify frail members of the older population. J Gerontol A Biol Sci Med Sci 68:441–446. CrossRefGoogle Scholar
  28. 28.
    Robinson TN, Wu DS, Sauaia A et al (2013) Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties. Ann Surg 258:582–588. (discussion 588–590) Google Scholar
  29. 29.
    Damhuis RA, Wereldsma JC, Wiggers T (1996) The influence of age on resection rates and postoperative mortality in 6457 patients with colorectal cancer. Int J Colorectal Dis 11:45–48Google Scholar
  30. 30.
    Mitry E, Bouvier A-M, Esteve J, Faivre J (2005) Improvement in colorectal cancer survival: a population-based study. Eur J Cancer 41:2297–2303. CrossRefGoogle Scholar
  31. 31.
    Kopetz S, Chang GJ, Overman MJ et al (2009) Improved survival in metastatic colorectal cancer is associated with adoption of hepatic resection and improved chemotherapy. J Clin Oncol 27:3677–3683. CrossRefGoogle Scholar
  32. 32.
    Padman S, Padbury R, Beeke C et al (2013) Liver only metastatic disease in patients with metastatic colorectal cancer: impact of surgery and chemotherapy. Acta Oncol 52:1699–1706. CrossRefGoogle Scholar
  33. 33.
    Malaguarnera M, Latteri S, Bertino G et al (2018) d-dimer plasmatic levels as a marker for diagnosis and prognosis of hepatocellular carcinoma patients with portal vein thrombosis. Clin Exp Gastroenterol 11:373–380. CrossRefGoogle Scholar
  34. 34.
    De Angelis R, Sant M, Coleman MP et al (2014) Cancer survival in Europe 1999–2007 by country and age: results of EUROCARE–5-a population-based study. Lancet Oncol 15:23–34. CrossRefGoogle Scholar
  35. 35.
    de Liguori Carino N, van Leeuwen BL, Ghaneh P et al (2008) Liver resection for colorectal liver metastases in older patients. Crit Rev Oncol Hematol 67:273–278. CrossRefGoogle Scholar
  36. 36.
    Nagano Y, Nojiri K, Matsuo K et al (2005) The impact of advanced age on hepatic resection of colorectal liver metastases. J Am Coll Surg 201:511–516. CrossRefGoogle Scholar
  37. 37.
    Adam R, Frilling A, Elias D et al (2010) Liver resection of colorectal metastases in elderly patients. Br J Surg 97:366–376. CrossRefGoogle Scholar
  38. 38.
    Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J et al (2013) Cancer incidence and mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 49:1374–1403. CrossRefGoogle Scholar
  39. 39.
    Sorbye H, Cvancarova M, Qvortrup C et al (2013) Age-dependent improvement in median and long-term survival in unselected population-based Nordic registries of patients with synchronous metastatic colorectal cancer. Ann Oncol 24:2354–2360. CrossRefGoogle Scholar
  40. 40.
    van Gestel YRBM, Lemmens VEPP, de Hingh IHJT et al (2013) Influence of comorbidity and age on 1-, 2-, and 3-month postoperative mortality rates in gastrointestinal cancer patients. Ann Surg Oncol 20:371–380. CrossRefGoogle Scholar
  41. 41.
    Biondi A, Vacante M, Ambrosino I et al (2016) Role of surgery for colorectal cancer in the elderly. World J Gastrointest Surg 8:606–613. CrossRefGoogle Scholar
  42. 42.
    van Steenbergen LN, Steur M, Lemmens VEPP et al (2013) Minimal excess mortality for long-term colon cancer survivors in the Netherlands 1989–2008. Eur J Cancer 49:585–592. CrossRefGoogle Scholar
  43. 43.
    Dekker JWT, van den Broek CBM, Bastiaannet E et al (2011) Importance of the first postoperative year in the prognosis of elderly colorectal cancer patients. Ann Surg Oncol 18:1533–1539. CrossRefGoogle Scholar
  44. 44.
    Fontani A, Martellucci J, Civitelli S, Tanzini G (2011) Outcome of surgical treatment of colorectal cancer in the elderly. Updates Surg 63:233–237. CrossRefGoogle Scholar
  45. 45.
    Strøm C, Rasmussen LS, Sieber FE (2014) Should general anaesthesia be avoided in the elderly? Anaesthesia 69(Suppl 1):35–44. CrossRefGoogle Scholar
  46. 46.
    Huisman MG, van Leeuwen BL, Ugolini G et al (2014) “Timed up & go”: a screening tool for predicting 30-day morbidity in onco-geriatric surgical patients? A multicenter cohort study. PLoS ONE 9:e86863. CrossRefGoogle Scholar
  47. 47.
    Sarfati D, Koczwara B, Jackson C (2016) The impact of comorbidity on cancer and its treatment. CA Cancer J Clin 66:337–350. CrossRefGoogle Scholar
  48. 48.
    Jafari MD, Jafari F, Halabi WJ et al (2014) Colorectal cancer resections in the aging US population: a trend toward decreasing rates and improved outcomes. JAMA Surg 149:557–564. CrossRefGoogle Scholar
  49. 49.
    Moghadamyeghaneh Z, Mills SD, Carmichael JC et al (2015) Risk factors of postoperative myocardial infarction after colorectal surgeries. Am Surg 81:358–364Google Scholar
  50. 50.
    Bakker IS, Grossmann I, Henneman D et al (2014) Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit. Br J Surg 101:424–432. (discussion 432) CrossRefGoogle Scholar
  51. 51.
    Guo M-G, Feng Y, Zheng Q et al (2011) Comparison of self-expanding metal stents and urgent surgery for left-sided malignant colonic obstruction in elderly patients. Dig Dis Sci 56:2706–2710. CrossRefGoogle Scholar
  52. 52.
    Ansaloni L, Andersson RE, Bazzoli F et al (2010) Guidelenines in the management of obstructing cancer of the left colon: consensus conference of the world society of emergency surgery (WSES) and peritoneum and surgery (PnS) society. World J Emerg Surg 5:29. CrossRefGoogle Scholar
  53. 53.
    Kurian A, Suryadevara S, Ramaraju D et al (2011) In-hospital and 6-month mortality rates after open elective vs open emergent colectomy in patients older than 80 years. Dis Colon Rectum 54:467–471. CrossRefGoogle Scholar
  54. 54.
    Morse BC, Cobb WS, Valentine JD et al (2008) Emergent and elective colon surgery in the extreme elderly: do the results warrant the operation? Am Surg 74:614–618 (discussion 618–619) Google Scholar
  55. 55.
    Modini C, Romagnoli F, De Milito R et al (2012) Octogenarians: an increasing challenge for acute care and colorectal surgeons. An outcomes analysis of emergency colorectal surgery in the elderly. Colorectal Dis 14:e312–e318. CrossRefGoogle Scholar
  56. 56.
    Waldron RP, Donovan IA, Drumm J et al (1986) Emergency presentation and mortality from colorectal cancer in the elderly. Br J Surg 73:214–216CrossRefGoogle Scholar
  57. 57.
    Bufalari A, Giustozzi G, Burattini MF et al (2006) Rectal cancer surgery in the elderly: a multivariate analysis of outcome risk factors. J Surg Oncol 93:173–180. CrossRefGoogle Scholar
  58. 58.
    Morris EJA, Taylor EF, Thomas JD et al (2011) Thirty-day postoperative mortality after colorectal cancer surgery in England. Gut 60:806–813. CrossRefGoogle Scholar
  59. 59.
    Marventano S, Grosso G, Mistretta A et al (2014) Evaluation of four comorbidity indices and Charlson comorbidity index adjustment for colorectal cancer patients. Int J Colorectal Dis 29:1159–1169. CrossRefGoogle Scholar
  60. 60.
    Kornmann VNN, van Vugt JLA, Smits AB et al (2017) The first year after colorectal surgery in the elderly. Ann Coloproctol 33:134–138. CrossRefGoogle Scholar
  61. 61.
    Mutch MG (2006) Laparoscopic colectomy in the elderly: when is too old? Clin Colon Rectal Surg 19:33–39. CrossRefGoogle Scholar
  62. 62.
    Frasson M, Braga M, Vignali A et al (2008) Benefits of laparoscopic colorectal resection are more pronounced in elderly patients. Dis Colon Rectum 51:296–300. CrossRefGoogle Scholar
  63. 63.
    Biondi A, Grosso G, Mistretta A et al (2013) Laparoscopic-assisted versus open surgery for colorectal cancer: short- and long-term outcomes comparison. J Laparoendosc Adv Surg Tech A 23:1–7. CrossRefGoogle Scholar
  64. 64.
    Vara-Thorbeck C, Garcia-Caballero M, Salvi M et al (1994) Indications and advantages of laparoscopy-assisted colon resection for carcinoma in elderly patients. Surg Laparosc Endosc 4:110–118Google Scholar
  65. 65.
    Hinoi T, Kawaguchi Y, Hattori M et al (2015) Laparoscopic versus open surgery for colorectal cancer in elderly patients: a multicenter matched case–control study. Ann Surg Oncol 22:2040–2050. CrossRefGoogle Scholar
  66. 66.
    Kannan U, Reddy VSK, Mukerji AN et al (2015) Laparoscopic vs open partial colectomy in elderly patients: insights from the American College of Surgeons—National Surgical Quality Improvement Program database. World J Gastroenterol 21:12843–12850. CrossRefGoogle Scholar
  67. 67.
    Zanghì A, Di Vita M, Borzì A et al (2018) Laparoscopic repair of incisional hernia. Risk factors for the conversion. Ann Ital Chir 89:242–246Google Scholar
  68. 68.
    Antoniou SA, Antoniou GA, Koch OO et al (2015) Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients. Surg Endosc 29:322–333. CrossRefGoogle Scholar
  69. 69.
    Janssen-Heijnen MLG, Maas HAAM, Houterman S et al (2007) Comorbidity in older surgical cancer patients: influence on patient care and outcome. Eur J Cancer 43:2179–2193. CrossRefGoogle Scholar
  70. 70.
    Vacante M, Borzì AM, Basile F, Biondi A (2018) Biomarkers in colorectal cancer: current clinical utility and future perspectives. World J Clin Cases 6:869–881. CrossRefGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2019

Authors and Affiliations

  1. 1.Department of General Surgery and Medical-Surgical SpecialtiesUniversity of CataniaCataniaItaly
  2. 2.Internal Medicine UnitMuscatello HospitalAugustaItaly

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