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The Impact of Age in the Treatment of Non-comorbid Patients with Rectal Cancer: Survival Outcomes from the National Cancer Database

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Abstract

Background

Multimodal therapy has improved survival outcomes for rectal cancer (RC) significantly with an exemption for older patients. We sought to assess whether older non-comorbid patients receive substandard oncological treatment for localized RC referring to the National Comprehensive Cancer Network (NCCN) guidelines and whether it affects survival outcomes.

Methods

This is a retrospective study using patient data from the National Cancer Data Base (NCDB) for histologically confirmed RC from 2002 to 2014. Non-comorbid patients between ≥50 and ≤85 years and defined treatment for localized RC were included and assigned to a younger (<75 years) and an older group (≥75 years). Treatment approaches and their impact on relative survival (RS) were analyzed using loess regression models and compared between both groups. Furthermore, mediation analysis was performed to measure the independent relative effect on age and other variables on RS. Data were assessed using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist.

Results

Of 59,769 included patients, 48,389 (81.0%) were assigned to the younger group (<75 years). Oncologic resection was performed in 79.6% of the younger patients compared to 67.2% of the older patients (p < 0.001). Chemotherapy (74.3% vs. 56.1%) and radiotherapy (72.0% vs. 58.1%) were provided less often in older patients, respectively (p < 0.001). Increasing age was associated with enhanced 30- and 90-day mortality with 0.6% and 1.1% in the younger and 2.0% and 4.1% in the elderly group (p < 0.001) and worse RS rates [multivariable adjusted HR: 1.93 (95% CI 1.87–2.00), p < 0.001]. Adherence to standard oncological therapy resulted in a significant increase in 5-year RS (multivariable adjusted HR: 0.80 (95% CI 0.74–0.86), p < 0.001). Mediation analysis revealed that RS was mainly affected by age itself (84%) rather than the choice of therapy.

Conclusions

The likelihood to receive substandard oncological therapy increases in the older population and negatively affects RS. Since age itself has a major impact on RS, better patient selection should be performed to identify those that are potentially eligible for standard oncological care regardless of their age.

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Acknowledgements

We thank the American College of Surgeons and the American Cancer Society for providing patient information through the NCDB used for this investigation. Furthermore, we thank the patients whose information through the NCDB allowed us to perform the investigation for this manuscript.

Funding

This study was in part supported by the Swiss Cancer Foundation.

Author information

Authors and Affiliations

  1. University of California San Diego, La Jolla, CA, USA

    Suna Erdem & Catherine Tsai

  2. Department of Surgery, Kantonsspital St. Gallen, 9007, St. Gallen, Switzerland

    Rene Warschkow & Bruno M. Schmied

  3. Department of Surgery, Hirslanden Clinic Beau Site, Bern, Switzerland

    Peter Studer & Mathias Worni

  4. Department of Surgery, Duke University, Durham, USA

    Daniel Nussbaum, Dan Blazer & Mathias Worni

  5. Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland

    Suna Erdem & Mathias Worni

  6. Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland

    Mathias Worni

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  1. Suna Erdem
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Contributions

SE, MW performed conceptualizing,SE, MW did methodology, RW done formal analysis and investigation, SE, JF, MW prepared writing—original draft preparation, SE, PS, CT, DN, BS, DB, MW done writing—review and editing, DN, DB, MW did resources, BS, DB, MW performed supervision.

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Correspondence to Mathias Worni.

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This retrospective cohort study was approved by the Duke Institutional Review Board. This article does not contain any studies with human participants performed by any of the authors.

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Erdem, S., Warschkow, R., Studer, P. et al. The Impact of Age in the Treatment of Non-comorbid Patients with Rectal Cancer: Survival Outcomes from the National Cancer Database. World J Surg 47, 2023–2038 (2023). https://doi.org/10.1007/s00268-023-07008-2

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