Commentary (Begossi/Wanebo): Surgery in the Older Patient
Commentary (Begossi/Wanebo): Surgery in the Older Patient
With this insightful manuscript, Drs. Termuhlen and Kemeny shed some light on the surgical management of older cancer patients. The authors highlight pitfalls in patient selection and offer proposals to improve the surgical oncologist’s approach to patient care. They review the role of curative surgical management of the most common forms of cancer in the elderly, while emphasizing the role of surgical palliation to improve the quality of life of older cancer patients.
Breast cancer is the most common cancer in women and the second most common cause of cancer-related death. Elderly patients with breast cancer, however, are at high risk for suboptimal screening and treatment. A previous review from Brown University demonstrated that women older than 65 years underwent screening mammography significantly less often than younger patients and, consequently, had decreased detection of preinvasive cancer. A higher percentage were undertreated, and within the undertreated group, there was a significant decrease in the survival rate.
At the time of that review, it was not possible to ascertain whether death in the older population was a consequence of cancer or comorbidity, or if the low screening rate was related to poor patient compliance. However, the link between screening mammography, early tumor detection, and breast conservation is well recognized.
Optimal treatment in elderly women is not standardized, and the enrollment of older females in clinical trials is limited. Older women are significantly less inclined to participate in clinical randomized trials and less aware of their meaning. The impact of physician concerns about surgery, drug toxicity, and noncancer death only partially justify this trend. National Cancer Institute (NCI)-sponsored clinical trials in elderly patients are currently in progress to define the best clinical approach. In the meantime, elderly patients should benefit from the same surgical and therapeutic approach used in younger patients, as summarized by a consensus of the National Institutes of Health.
Among cancers, colorectal, stomach, and pancreatic are most prevalent in the over-65 population. Clinical staging and elective and curative surgeries vs emergency and palliative surgery represent the most important outcome prognosticators. Survival and recurrence rates for these cancers are less likely to be modified by age than by disease stage, cardiopulmonary status, anesthesia risk score, or type of surgery performed (curative vs palliative). Adequate surgery plus adjuvant treatment may improve the prognosis of higher-risk elderly as well as younger patients.[7-9]
Surgery in the Elderly
The role of age in the treatment of liver metastases from colorectal cancer is controversial. We analyzed the outcome of 74 patients who underwent hepatic resection of colorectal metastases in order to define a perioperative selection protocol. Extent of resection and distribution of metastases had a significant impact on survival. An analysis of the survival trend favored the elderly patients. The median and 5-year actuarial survival rate in 26 patients older than age 70 was 47 months and 31%, respectively; the same measures for 27 patients younger than age 60 were 29 months and 19%; 21 patients aged between 61 and 70 had intermediate data. These differences were not significant, but they support the theory that older patients with liver metastases may tolerate curative liver resection surgery.
However, elderly patients have a lower tolerance for extended resections. Fortner et al suggested that extended resection in patients aged 65 to 82 was associated with an increase in mortality. In our study, 5% of patients older than age 60 (mean age: 67), all of whom underwent major hepatic resection, died of delayed liver failure (after 30 to 60 days). Compromised liver function in the older patient, coupled with extensive surgical resection, appeared to be responsible for this outcome (ie, due to insufficient hepatic reserve). Major hepatic resection in older patients is a higher-risk procedure and should be avoided, especially in patients with impaired liver reserve and those in whom extended resection is essential for cure. Secondary techniques (radiofrequency ablation or hepatic artery infusion) may be necessary.
Surgery in the older patient warrants some considerations. The population of persons older than 65 is increasing progressively. Currently, 13% of Americans are over 65, but by the year 2030, it is estimated that this percentage will increase to 20%. Cancer incidence and mortality rates increase dramatically with age and are, respectively, 11 and 15 times greater in people over age 65 than in their younger counterparts.
Remaining life expectancy in individuals over age 65 is 13 to 19 years, and in those aged 80 to 85, 7 to 9 years. Moreover, 60% of cancer patients are over age 65. Physicians tend to underestimate the potential for functional life in older patients, especially if their disease can be controlled.
There is a bias governing the selection of elderly patients for treatment. Calendar age and the influence of preexisting diseases are often considered exclusionary criteria for surgical treatment or enrollment in clinical trials. This results in frequent underestimation of the true clinical status of the patient and a compromise in treatment. Because elderly patients are generally excluded from clinical randomized trials, our understanding of the interaction of new treatments in elderly patients, with or without comorbidity, is inadequate. We need more data on the effect of new treatments in elderly patients, and this requires carefully conducted clinical trials.
Another issue concerns how "elderly" should be defined. The definition of elderly with the classic cut-off at 65 years is misleading. The aging process differs from one individual to another. It is important to consider the entire health status of the patient, including physical, psychological, nutritional, and physiologic aspects. Age brings on natural variations in organ function—ie, of the liver, kidney, and heart—that may deserve particular attention when designing protocols involving certain drugs or therapies.
The evaluation of preexisting diseases is crucial in the management of the older patient. The term "comorbidity" is used to define concurrent disease at the time of tumor diagnosis. Comorbidity, aging, and cancer are commonly associated, and 68% of patients with cancer have comorbid disease. The number of concurrent diseases increases with age—from 3.6 in 65- to 74-year-old patients to 4.2 in patients over 75.
Currently, there are no data from clinical trials showing the effect of comorbidity on the surgical treatment of older cancer patients. However, most observational and retrospective studies demonstrate that older patients may tolerate surgery, whether for benign or malignant disease—even extensive surgery such as pelvic exenteration and sphincter-preserving rectal cancer procedures. Moreover, older patients also appear to tolerate chemotherapy and radiation, according to some reviews.[15,16]
An old adage from our surgical teachers is that older patients can usually tolerate the surgery as well as younger patients, but do not tolerate the complications as well. Good patient selection and careful selection and performance of surgical procedures with aggressive postoperative care and rehabilitation should facilitate survival of older patients and provide them with good quality of life.
Clinical Trials in the Elderly
Recruitment of older patients into clinical trials is critical. An analysis of 16,000 patients from 164 clinical trials conducted by the Southwest Oncology Group from 1993 to 1996 showed an underrepresentation of the population over 65 (25% vs 63% in the under 65 group). The National Institutes of Health is currently sponsoring 358 clinical trials of surgery in cancer patients (see http://www.cancer.gov/clinical_trials/). The majority of these trials are open-aged, but criteria for enrollment are extremely variable or not specified. Only two involve the elderly: one comparing breast surgery, with or without nodal dissection, in females older than age 60, and the other comparing two chemotherapeutic protocols in females older than 65.
Unfortunately, older patients and their families are uninformed about clinical trials and do not understand the potential benefit of participating in a trial. (In most cases, the overall treatment is better.) Only 3% of Americans participate in clinical trials. Although clinical trials are essential for the development of treatment guidelines, Medicare does not cover expenses generated in clinical trials, and physicians discourage participation on the basis of chronologic age and preexisting disease.[4,17]
Comorbidity should be managed so as to facilitate recruitment to clinical trials as well as to facilitate standard therapy. The older patient should generally be able to receive treatment similar to that of his younger colleagues. The adoption of preventive measures to limit comorbidity, and screening procedures to detect early cancer are recommended. Primary care should be integrated with the strategies of the multidisciplinary oncology team. Cancer staging should be detailed, and clinical situations responsible for high morbidity and mortality, such as emergency surgery, should be avoided. Thus, colorectal screening along with identification of an early-stage cancer will yield a better outcome after cancer surgery and therapy than if the same patient were to undergo emergency surgery for an obstructing colorectal cancer.
Improvement of critical and intensive care may also help to ameliorate the patient’s outcome in the short-term postoperative period. The collaboration of the oncology staff with geriatricians, family, and the rehabilitative social and home care services will contribute greatly to supporting communication with patients and their families and improve long-term care and the quality of life of elderly patients. Early detection and treatment may best curtail the cost of cancer management.
The eldery bear most of the burden of cancer. Physiologic aging and comorbidity can diminish the patient’s health status and hinder the administration of appropriate treatment. An aggressive and effective multidisciplinary health-maintenance approach represents the best solution to safeguarding quality of life in the elderly.
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