Cause of death the first year after curative colorectal cancer surgery; a prolonged impact of the surgery in elderly colorectal cancer patients

doi:10.1016/j.ejso.2014.05.010

European Journal of Surgical Oncology (EJSO)

Volume 40, Issue 11, November 2014, Pages 1481-1487

https://doi.org/10.1016/j.ejso.2014.05.010 Get rights and content

Abstract

Background

The 1-year mortality after colorectal cancer surgery is high and explains age related differences in colorectal cancer survival. To gain better insight in its etiology, cause of death for these patients was studied.

Methods

All 1924 patients who had a resection for stage I–III colorectal cancer from 2006 to 2008 in the Western region of the Netherlands were identified. Data were merged with cause of death data from the Central Bureau of Statistics Netherlands. To calculate excess mortality as compared to the general population, national data were used.

Results

Overall 13.2% of patients died within the first postoperative year. One-year mortality increased with age. It was as high as 43% in elderly patients that underwent emergency surgery. In 75% of patients, death was attributed to the colorectal cancer. In 25% of all patients, registered deaths were attributed to postoperative complications. Elderly patients with comorbidity more frequently died due to complications (p < 0.01). Death of other causes was similar to background mortality according to age group.

Conclusion

In the presently studied cohort of patients that died within one year of surgery, cause of death was predominantly attributed to colorectal cancer. However, because it is not to be expected that in this cohort the number of deaths from recurrences is very high, the excess 1-year mortality indicates a prolonged impact of the surgery, especially in elderly patients. Therefore, in these patients we should focus on limiting the physiological impact of the surgery and be more involved in the post-hospital period.

Introduction

Recently there has been an increasing emphasis on peri-operative risk in colorectal surgery.

In this respect the surgical management of the elderly patient forms one of the most prominent issues. The elderly population is very heterogeneous and although excellent results of colorectal cancer surgery in these patients are reported,1, 2 comorbidity and frailty challenge surgical management in these patients.

An important outcome measure for surgery is postoperative mortality. This is usually described as mortality within thirty days after surgery. However, recent studies have shown that 30-day mortality after surgery is not an appropriate measure of surgical risk, as a significant proportion of patients die beyond this period.3, 4, 5 Especially in elderly patients a significant proportion fails to thrive in the months that follow colorectal surgery. The excess mortality beyond thirty days has been shown to sustain up to one year after surgery. It is the single most important explanation for age related differences in colorectal cancer survival.⁶ But even in younger colorectal cancer patients that underwent curative surgery a significant 1-year excess mortality exists. In high risk patients this can even increase to 15–30%.⁷ This shows that the deleterious physiological impact of surgery and postoperative complications is not limited to the immediate postoperative period. Considering the large impact on overall and disease-specific survival, information on the etiology of the 1-year excess mortality is important. Earlier studies identified risk factors such as high age, emergency surgery, postoperative complications and re-admittance.7, 8, 9 However, up to date information on the cause of death for these patients is limited.

To improve overall care for elderly colorectal cancer patients it is important to know whether patients die as a consequence of their cancer, the treatment they receive or by competing causes of death. This could allow for improvements in the care for and counseling of elderly colorectal cancer patients. It could also provide important information for outcome registrations and audits.

The aim of this study is to gain a better insight in the etiology of the 1-year excess mortality by studying cause of death in a population based cohort of stage I–III colorectal cancer patients, with a special emphasis on elderly patients.

Section snippets

Data

In the Netherlands, all newly diagnosed malignancies are registered in the nationwide population based Netherlands Cancer Registry (NCR). The Leiden Cancer Registry, part of the NCR, collects data on all cancer patients diagnosed in one of the nine affiliated hospitals in the western part of the Netherlands. This region comprises one university hospital, six teaching hospitals and two non-teaching hospitals and serves a population of 1.7 million inhabitants.

Independently trained data managers

Results

From January 1st 2006 through December 31st 2008, 1924 patients had a resection in one of the nine affiliated hospitals of the Leiden Cancer Registry, for stage I–III colorectal cancer; 1279 for colon cancer and 645 for rectal cancer. These resections were R0 in 94.3%, R1 in 1.9%, R2 in 1.3% and in 2.5% of patients R-status was not registered. Table 1 shows the characteristics of the study population. Overall 13% of patients died within the first postoperative year. Besides gender and year of

Discussion

The reliability of cause of death coding in The Netherlands has been shown to be high for major causes of death such as cancer and myocardial infarction, but for chronic diseases it can be low.¹⁴ The accuracy of cause of death statements has been debated in many studies.15, 16, 17 The attribution of the cause of death depends on judgments of the possible pathway of morbid events leading directly to death by both the physician completing the death certificate and the coding medical registry

Conclusions

Cause of death statements on death certificates should be interpreted with care. In the presently studied cohort of stage I to III colorectal cancer patients that died within one year of surgery, cause of death was predominantly attributed to colorectal cancer. Because it is not to be expected that in this cohort the number of deaths from recurrences is very high, the excess 1-year mortality indicates a prolonged impact of the surgery. This is supported by the finding that up to 25% of deaths

Conflict of interest statement

All authors have no conflict of interest to report.

Acknowledgments

The authors would like to thank the Central Bureau Statistics Netherlands for the opportunity to use cause of death certificates for this study. The authors would also like to acknowledge the professional network of surgical oncologists, the steering group of the KIC-project and the Comprehensive Cancer Centre the Netherlands for their advice, and the registrars of the Leiden Cancer Registry for the collection of the data. The additional data collection in the KIC-project was financially

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Cause of death the first year after curative colorectal cancer surgery; a prolonged impact of the surgery in elderly colorectal cancer patients

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Data

Results

Discussion

Conclusions

Conflict of interest statement

Acknowledgments

Am J Surg

J Clin Epidemiol

J Am Coll Surg

J Am Coll Surg

Surgery

Br J Anaesth

Colorectal surgery in octogenarian patients – outcomes and predictors of morbidity

Int J Colorectal Dis

Death after colectomy: it's later than we think

Arch Surg

Elective colonic surgery for cancer in the elderly: an investigation into postoperative mortality in English NHS Hospitals between 1996 and 2007

Colorectal Dis

Is 30 day mortality an appropriate measure of risk in elderly patients undergoing elective colorectal resection?

Colorectal Dis

Importance of the first postoperative year in the prognosis of elderly colorectal cancer patients

Ann Surg Oncol

Risk factors for excess mortality in the first year after curative surgery for colorectal cancer

Ann Surg Oncol

Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival

Anesth Analg

Readmission after colectomy for cancer predicts one-year mortality

Ann Surg

International classification of diseases for oncology