Elsevier

The Lancet

Volume 356, Issue 9234, 16 September 2000, Pages 968-974
The Lancet

Articles
Surgery for colorectal cancer in elderly patients: a systematic review

https://doi.org/10.1016/S0140-6736(00)02713-6Get rights and content

Summary

Background

The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients.

Methods

We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65–74 years, 75–84 years, and 85+ years were expressed in relation to those aged less than 65 years.

Findings

From 28 independent studies, and a total of 34194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking.

Interpretation

The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

Introduction

Colorectal cancer is predominantly a disease of elderly people and is a major cause of morbidity and mortality in the elderly population. It is the second most common cancer in the UK, but the most common malignant disease in elderly people, since over 70% of cases occur in those aged 65 years or older.1 The number of cases in elderly people is expected to increase as the population ages.

Colorectal cancer is managed with surgical resection of the primary tumour whenever possible, either for cure or palliation, to avoid late complications, such as obstruction and perforation. The surgical procedure chosen depends mainly on the position of the tumour in the bowel and whether the patient presents electively or as an emergency. Long-term survival is related to the extent of disease at diagnosis.2 Survival of emergency cases is much poorer than in those who undergo elective surgery as a result of a higher perioperative mortality rate after emergency surgery, related to the more advanced tumour stage and poor physical status of patients at presentation.3, 4

Clinicians frequently have to decide whether major surgery is justified in elderly patients with a limited life-expectancy. Effectiveness of surgery in elderly patients depends upon whether it is done safely, allowing patients to return to productive lives, with a postoperative life-expectancy that is improved, or at least not diminished by the surgical procedure. The importance of appropriate treatment does not diminish with age, because inadequate treatment in older cancer patients is associated with poor survival.5 Although advances in surgical techniques, anaesthetic procedures, and postoperative care have all made surgery less hazardous, fewer elderly patients undergo resection for colorectal cancer than their younger counterparts.6, 7, 8, 9 This difference might be because of later presentation, poor performance status, presence of substantial comorbidities, or expectation of a poor outcome in elderly patients.10, 11 The outcome of major surgery in elderly patients could be similar to that in younger people if careful selection and appropriate attention to detail is exercised.12, 13 Nevertheless, in elderly patients at very high risk, the choice of surgical procedure might need to be modified.14

The risks and benefits of surgery for colorectal cancer have not been clearly defined in elderly patients. We aimed to compare the outcomes of primary surgery for colorectal cancer in the elderly patient population consisting of the young-old (65–74 years), the older-old (75–84 years), and the oldest-old (≥85 years)15 with those in younger patient groups.

Section snippets

Methods

We have undertaken a systematic review of published data together with unpublished data provided by investigators according to predefined protocol (available from authors).

Patient characteristics

Patients were nearly equally distributed between the age groups of less than 65 years (11 600, 34%), 65–74 years (10 863, 32%), and 75–84 years (9164, 27%). The 85+ year age group consisted of only 8% (2567) of all patients. The proportion of patients under 65 years ranged from 23 to 72% and the proportion under 75 years ranged from 54 to 94%. For comparison, the age-related frequency of colorectal cancer in the UK population1 was 26% in those under 65 years, 31% in those aged 65–74 years, 31%

Discussion

One of the difficulties of assessing the outcomes of surgery for colorectal cancer in elderly patients is that there is no consistent definition of the elderly patient population in published studies. Additionally, there is considerable variation in the way in which outcomes are reported, which limits comparison of different series. The data that we have for 34 194 patients subdivided by age is an invaluable resource that has allowed us to compare outcomes in elderly patients with those under

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