Colonic cancer is one of the most commonly diagnosed malignancies in men and women in developed countries. The disease rarely occurs before age of 40 and the risk of colonic cancer is the highest around age of 70. Seventy-five percent of colon tumors are found in patients aged 65 years or older [
The incidence of colonic cancer has increased in the last decades. With the increase of age in the general population in developed countries the next future decades, the number of elderly patients who present with this disease will increase [
Therefore, curative surgery of colonic cancer in elderly patients is debatable, especially in the very elderly patients, who have limited prospects of survival. Some authors promote extensive surgery, including multistage procedures, as performed in younger patients [
The aim of this study was to evaluate the outcome of colonic surgery in the elderly in our hospital to determine the best treatment strategy in this patient category.
In the period January 1999–January 2004, 207 consecutive patients underwent surgery for stages I–III colonic cancer. Patients with rectal cancer and patients that presented with distant metastases were excluded. All patients were separated into two groups, one group with patients younger than 75 years and one group with patients older than 75 years.
This separation was based on several other publications concerning this subject [
The following data were collected for each patient: gender, age, location, and characteristics of the tumour, type of operation, duration of admittance, ICU admittance, comorbidity, complications, type of ileostomy/colostomy, disease-free survival, and overall survival.
Comorbidity was classified according to an adapted version of Charlson et al. and was divided into previous malignancies, COPD, cardiovascular disease, cerebrovascular disease, hypertension, diabetes, and other [
Followup was conducted according to the criteria of the Dutch Cancer Centre recommendations.
Statistical analyses were performed using SPSS 13.0 (SPSS, Chicago, Ill, USA). Mann-Whitney
Seventy-four of 207 patients (36%) were 75 years or older when operated upon, male: female 30 : 44. The mean age of the elderly patients was 80 years [range 75–100] compared with a mean age of 62 years in the group
In the younger group, 11 patients (9%) presented as a surgical emergency (
In the elderly group thirteen patients (81%) had abdominal complaints for less than 3 weeks.
In the other 3 patients there was serious patient delay because all had significant complaints for more than 6 weeks and refused to seek medical care. In the younger patients that were operated upon in an emergency setting, none of them had symptoms a month prior to operation.
No differences were found in tumor location, depth of invasion, or Dukes’ stage.
Patients’ characteristics and tumor features are summarized in Table
Patient and tumor characteristics.
% | % | ||||
---|---|---|---|---|---|
No. of patients | 133 | 64% | 74 | 36% | |
Emergency setting | 11 | 9% | 16 | 22% | |
Location of tumor | |||||
Right hemicolon | 58 | 44% | 41 | 55% | NS |
Left hemicolon | 22 | 17% | 6 | 8% | NS |
Sigmoid | 49 | 36% | 25 | 34% | NS |
Double tumor | 4 | 3% | 2 | 3% | NS |
Invasion depth | |||||
T1 | 8 | 6% | 1 | 1% | NS |
T2 | 21 | 16% | 11 | 15% | NS |
T3 | 87 | 65% | 51 | 69% | NS |
T4 | 17 | 13% | 12 | 15% | NS |
Dukes’ classification | |||||
A | 12 | 9% | 8 | 11% | NS |
B | 60 | 45% | 35 | 47% | NS |
C | 61 | 46% | 31 | 42% | NS |
The mean number of days of admittance to the hospital in the elderly group was 16.5 days [range 2–68]. The mean number of days of admittance to the ICU was 2.3 days [range 0–38]. In the group
Elderly patients more often presented with significant comorbidity (Table
Comorbidity.
Comorbidity | % | % | |||
---|---|---|---|---|---|
Other malignancy | 13 | 10% | 9 | 12% | NS |
COPD | 12 | 9% | 10 | 13% | NS |
Cardiovascular | 33 | 25% | 36 | 49% | |
CVA | 7 | 5% | 3 | 4% | NS |
DVT | 0 | 0% | 1 | 1% | NS |
Hypertension | 10 | 8% | 11 | 14% | NS |
DM | 15 | 11% | 8 | 11% | NS |
Other | 5 | 4% | 9 | 12% |
Table
Type of operation and stomata.
Type of operation | % | % | |||
---|---|---|---|---|---|
Ileocecal resection | 3 | 2% | 3 | 4% | NS |
Hemicolectomy right | 56 | 42% | 36 | 49% | NS |
Transversum resection | 2 | 1% | 2 | 3% | NS |
Hemicolectomy left | 18 | 15% | 6 | 8% | NS |
Sigmoidresection | 35 | 26% | 16 | 22% | NS |
Anteriorresection | 13 | 10% | 7 | 9% | NS |
Subtotal colectomy | 4 | 3% | 1 | 1% | NS |
Double resection | 2 | 1% | 3 | 4% | NS |
Stomata | |||||
No. of primary anastomoses | 115 | 86% | 63 | 85% | NS |
Total no. of stomata | 18 | 14% | 11 | 15% | NS |
End ileostomy | 2 | 10% | 1 | 9% | NS |
End colostomy | 9 | 50% | 4 | 36% | NS |
Loop ileostomy | 6 | 21% | 3 | 27% | NS |
Loop colostomy | 1 | 5% | 3 | 27% | NS |
In 85% of the elderly patients and in 86% of the younger patients, a primary anastomosis was made. No significant difference was found in the number and types of ileo- and colostomies.
Complications were seen in 32 younger patients (24%) and in 37 elderly patients (50%) (
Significant however was the higher number of pneumonias, wound infections, and minor complications (i.e., urinary tract infection, and electrolyte disturbances) in the elderly group (
Complications.
% | % | ||||
---|---|---|---|---|---|
Total no. of complications | 32 | 24% | 32 | 43% | |
Anastomotic leakage | 7 | 5% | 4 | 5% | NS |
Fascia dehiscention | 5 | 4% | 2 | 3% | NS |
Pneumoniae | 5 | 4% | 10 | 14% | |
Intraabdominal abscesses | 5 | 4% | 0 | 0% | NS |
Delerium | 21 | 16% | 28 | 38% | |
Woun dinfection | 1 | 1% | 6 | 8% | |
Ileus | 6 | 5% | 6 | 8% | NS |
Minor complications | 6 | 5% | 10 | 14% | |
In-hospital mortality | 6 | 5% | 12 | 16% |
The in-hospital mortality was 16% (12 patients) in the elderly and 5% (6 patients) in the younger group (
Of all elderly patients that died, 5 died of sepsis and multiple organ failure, 3 due to pneumonia or respiratory failure, 2 due to myocardial infarction, and 1 due to a high gastrointestinal bleeding. In the younger patients, 3 died of sepsis and 2 due to respiratory failure. A palliative resection was performed in 2 patients, each in one group. Unfortunately, these 2 patients were in such worse condition that they died after prolonged ICU admittance. The five-year survival rate of patients, who were treated with curative resection, was 62% in the younger group compared with 36% in the elderly (
Kaplan-Meier 5-year overall-survival curve. Blue solid line for patients
Significant however was the number of deaths during 5-year followup which were not (colonic) cancer related, in the younger group
Only 6 patients in the elderly group received adjuvant chemotherapy (8%), while 33 patients were qualified for adjuvant therapy. In the younger group 40 patients (30%) received adjuvant therapy, while 68 patients were qualified. Besides age, the main reason not to give adjuvant treatment was a low Karnovsky index.
DFS was 61% in the younger patients compared with 32% in the elderly (
Surgical resection remains the core in curative treatment for colonic cancer. Due to the steadily expansion of the elder population in the industrialized world, surgeons will be confronted with more and more elderly patients.
In a systematic review, which was published in the Lancet in 2000, it is demonstrated that in elderly patients less often a resection of the tumour is performed than in younger patients [
However, studies have shown that age alone is not a significant prognostic factor in survival after colonic surgery [
Therefore, it is better to speak of biological age rather than chronological age when assessing risk factors for surgery, which focuses more on the overall condition of the patient.
Because treatment options in colonic cancer increase, recent literature shows a decrease in resection rate between elderly and younger patients [
Specific problems related with elderly patients are, as mentioned earlier, a significant higher number of comorbidities, prolonged in-hospital stay, and a delayed or emergency presentation. In our study 77% of the elderly had at time of surgery one or more types of comorbidity. This corresponds with other studies, which report an incidence of 70%–85% [
Most patients in the elderly group were classified as ASA III.
It is well documented that emergency surgery is related with a higher mortality rate than elective surgery [
When we compare 5-year survival between the patients that were operated in an emergency setting with the patients who were operated electively, there was a significant difference in 5-year survival (39% versus 56%) (
In-hospital stay did not significantly differ between the two groups. This is remarkable because of the high number of postoperative complications (pneumonias, cardiovascular problems, and deliriums) in the elderly group. Delirium is a known, serious complication with high incidence in elderly patients. It increases the chance of other complications, a longer duration of admittance, worse recovery (physically and mentally), and a higher mortality [
In our study, we found significantly more deliriums in elderly patients. In a study, which recently took place in our clinic, to determine the incidence of delirium after elective abdominal surgery, an incidence of 24% was found as well as a higher mortality rate [
The incidence of delirium in our study was 23%.
The type of surgery also did not differ between the two groups. In both groups the same percentage of ileo- or colostomies was performed. In a study done by Lemmens et al. it was demonstrated that elderly patients with comorbidity were treated less aggressively and therefore had worse survival [
Remarkable in followup was that 33% of the patients that died in the elderly group died of noncolonic cancer-related causes which could be linked to preoperative comorbidities. In the younger group this was only 8%. After correction for colonic cancer-related 5-year survival, no significant difference could be found between the two groups.
Curative resection of colonic carcinoma in the elderly is well tolerated and age alone should not be an indication for less aggressive therapy. However, the type and number of comorbidities influence postoperative mortality and morbidity. Treatment of these comorbidities prior to surgery may influence postoperative outcome.