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Surgical Resection

Chapter 05 - Surgical Treatment

Inappropriately, chronological age is still considered to be a factor to decline surgery by some physicians. A large survey of primary care providers in France, showed that chronological age of the patient was highly associated with the decision not to refer patients with advanced cancer (not defined) to oncologic specialties (odds ratio 0.55; 95% confidence interval 0.35-0.86; p = 0.009). If elderly patients are referred to an oncologic specialty, age being a barrier to treatment may exist there too. In a survey of 1408 French medical and radiation oncologists, to whom breast cancer patients were referred, significant differences in treatment choice were observed based solely on patient age.

Surgical resection, when feasible, is one of the most successful modalities of therapy for solid cancers. Age is becoming less important when deciding if surgery is appropriate. The acceptance of this surgical philosophy is different throughout the world, as it is not uncommon in some countries for surgeons to routinely perform cancer resections on patients with multiple comorbidities and increased frailty. A study analysing data at the Eindhoven Cancer Registry has shown an acceptance rate of 95% for surgical resection in non-metastatic colorectal cancer patients who are elderly. This study involved 8,000 patients aged between 50 to 80 years old with colon, rectal and other cancers. A study comparing outcomes of colorectal cancer resection among 32,621 Veterans Administration patients, between temporal cohorts of 1987 to 1993 and 1994 to 2000, found significantly more patients aged 80 year or older received surgical resection in the 1994-2000 time period. A study by Nascimbeni R. et al, also looking at the temporal trends in patients undergoing colorectal cancer resection, compared outcomes between 1975 to 1984 and 1995 to 2004 and found surgical patients aged 75 years or more increased from 19% to 29%, furthermore those aged 85 years or older, doubled from 3% to 6%.

In addition to the increase surgical intervention in elderly cancer patients, doctors are also increasingly looking at the various curative options with multimodality therapy. The importance of targeting appropriate treatment does not diminish with age, because inadequate treatment in older cancer patients is associated with poor survival. A study reviewing the treatment and survival of older (>75 years of age) cancer patients, in a Danish national cancer registry, found the proportion of patients who were denied treatment, or received only palliative therapy, decreased by 35% from 19.8% in the period of 1977 to 1982 to 13.1% in the period of 1995 to 1999. This study also found that the proportion receiving “curative” therapy increased from 36% to 49.2% during these same time intervals.

When a decision to perform surgery is made and the basic assessments are in favour of a surgical intervention, the question to be asked is, with a curative intent operation in the elderly what sort of invasive procedure is to be performed? This is crucially relevant for those patients undergoing major surgical procedures, like thoracic and abdominal procedures, as they have the greatest risks associated with them.

Lung Cancer

Lung cancer is primarily a disease of the elderly. More than 65% of lung cancer patients are older than  65 years of age, when diagnosed. The standard of care for patients of any age, with resectable lung cancer, has been anatomic lung lobectomy (the relative risks and efficacy of lesser resections [i.e. segmentectomy] are being evaluated in clinical trials). In large randomised trials a lobectomy is associated with a mortality of 1.4%, no increased risk has been found to be associated with advanced age. However, these and several smaller studies have not characterised the elderly sufficiently well. Alternative therapies, such as ablation or radiation, have been used for patients who were not deemed fit for surgery, but the criteria used to identify such patients has not been clearly explained.

Colorectal Cancer

More than half of patients diagnosed with colon cancer are older than 65 years of age. Approximately 70% are diagnosed at an early stage, when surgical resection is the cornerstone of treatment. Curative resection of colonic carcinoma is well tolerated in the elderly. Age alone should not be an indication for less aggressive therapy. The elderly may have more comorbidities which can influence postoperative mortality and morbidity. Therefore, Careful patient selection for surgical procedures is important. Frail elderly patients are at a higher risk of both mild and severe complications, compared to elderly patients who are who are not considered to be frail. Laparoscopic surgery seems to be associated with improved short-term outcomes. In a systematic review of comparative outcomes of elderly and non-elderly patients with rectal cancer, postoperative morbidity was as high as 40% in elderly patients, but not significantly higher than in younger patients. Patients who survived the first year after surgery showed similar outcomes as their younger counterparts.

Liver Tumours and Metastasis

Primary or secondary liver tumours are subject to liver resection even in senior patients. Improvements in anaesthesia, postoperative management, surgical techniques and technologies have resulted in better outcomes. However, morbidity and mortality remain high, when compared with those for other types of surgery. Several retrospective studies have shown that liver resection can be performed safely in elderly, but their length of hospital stay and their discharge to rehabilitation facilities is higher when compared to their younger counterparts. Two multi-institution series have evaluated outcomes of elderly patients undergoing liver surgery. One series reported on the outcomes of 856 patients who underwent major hepatectomy. The patients were divided into groups (>50, 50 to 64, 65 to 74, and ≥75 years) age was independently associated with surgical mortality (odds ratio 1.039; 95% CI, 1.021 to 1.058; p = 0.0029). Another large series evaluated 7,764 patients who underwent liver resection to treat colorectal liver metastases. Compared with patients younger than 70 years of age, those older than 70 years had an increased 60-day mortality (3.8% v 1.6%; p < 0.001), as well as increased postoperative complications (32.3% v 28.7%; p. < 0.001). However, patients do benefit from surgery when they are fit. Therefore, surgical options should be considered as appropriate interventions, but caution is needed.

Pancreatic Cancer

Pancreatic resection, when feasible, is the mainstay of treatment for pancreatic cancer. Large population-based studies in the pancreatic literature suggest worse short-term outcomes in older patients, compared to younger patients. When large series of elderly patients undergoing major pancreatic or hepatobiliary operations are analysed, chronological age turns out not to be a meaningful risk factor, although the consensus is that physiologic age is essential to consider. When the contribution of chronologic age was isolated statistically, using logistic regression modelling with pseudo r^2 analysis in one of the world’s largest series of pancreaticoduodenectomy, age alone was found to contribute to less than 1% of morbidity and mortality. Much more important was chronic obstructive pulmonary disease and coronary artery disease, which had a nearly 4-fold and 5-fold increased impact, respectively.

Thus, liver and pancreas resections can be safely performed, although older patients are at higher risk for perioperative mortality, which reinforces the need for better assessment tools and perioperative interventions.

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