Surgery for Colorectal Cancer in Older People

Abstract

Life expectancy has been increasing, and an increasing number of older patients are presenting with colorectal cancer. Surgical management of colorectal cancer in these patients poses a unique challenge, requiring a multidisciplinary team approach, as they have more comorbidities and lower functional reserves. An accurate diagnosis, a thorough patient assessment and individualized treatment is crucial in order to achieve the best possible outcome. While the overall postoperative mortality rates were significantly higher in the over 75 age group, it seems that age itself is not a risk factor for surgery. Older patients presented with more locally advanced disease, a factor that increased the overall postoperative mortality. Comorbid conditions increase the risk of postoperative mortality in these patients. When comparing different age groups with similar American Society of Anesthesiologists (ASA) scores, no significant difference was found in postoperative mortality. Laparoscopic surgery was shown to be beneficial for the elderly, with low morbidity and mortality and a shortened hospital stay. Patients with rectal cancer benefit from transanal endoscopic surgery as a primary procedure or as part of a ‘watch and wait’ strategy following neoadjuvant chemoradiotherapy. Early elective surgery and the avoidance of emergency major surgery whenever possible, by for example the use of stents followed by elective resection in cases of colonic obstruction, will help improve outcomes.

1. Introduction

Colorectal cancer (CRC) is the third most common cancer worldwide, and the second leading cause of cancer-related deaths. Approximately 1.8 million new cases of CRC and 900,000 colorectal cancer-related deaths were recorded in 2018. The incidence of CRC is increasing worldwide. About 60% of CRC patients are over the age of 70 years at diagnosis, and about 40% are aged over 75 years [1].

The global population is aging. In fact, according to the World Health Organization, 11% of the world’s population was over 60 years old in 2006, with an expected rise to 22% by 2050. A majority of these elderly patients are frail and have a number of comorbid illnesses and lower functional reserves, as well as potential psychological and social care issues [2].

Surgical resection is the standard treatment for CRC. The surgical management of these patients is challenging, requiring a multidisciplinary team approach. An accurate diagnosis, a thorough patient assessment and individualized treatment is crucial in order to achieve the best possible outcome.

2. Surgical assessment of the older patient

The number of older people undergoing surgery, both open and laparoscopic, has been increasing over the years. This increase is mainly attributed to improvements in living conditions, longer life expectancy, advances in surgical, and anesthetic techniques, as well as changes in the expectations of both the patient and the clinician. Despite all this, older surgical patients remain at increased risk of developing adverse postoperative outcomes when compared to younger patients.

A thorough assessment of an older patient with colorectal cancer is, therefore, important in order to aid therapeutic decisions [3, 4, 5, 6, 7, 8]. Functional levels vary widely. At one end of the spectrum are patients who are robust and able to tolerate surgical and oncological treatment well, while at the other end are patients who are frail and unable to tolerate even minor procedures without the risk of life-threatening complications.

Treatment decisions are clear at either end of this spectrum, but less clear otherwise. Formal assessments are, therefore, necessary to identify those at risk of functional decline and to determine the degree of frailty of these older patients. The results of these assessments may, thus, help in tailoring the treatment to the individual patient. When choosing between various treatment options, the quality of life is at least as important for these patients as the cancer-specific or surgical outcome [9].

A number of factors are taken into account during the assessment of the older patient with colorectal cancer. These include:

1. Estimating life expectancy based on functional evaluation and comorbidities.

2. Estimating the risk of cancer-related morbidity. This is achieved by accurately staging of the tumor, and by assessment of tumor aggressiveness, the risk of recurrence and tumor progression.

3. Evaluation, using the comprehensive geriatric assessment (CGA), of the conditions that could interfere in the treatment of the patient’s cancer. The CGA is defined by the British Geriatrics Society as a ‘multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up.’

4. Assessment of the patient’s goals and expectations of treatment. An important aspect of this assessment is quality of life. Quality of life is a multidimensional construct, representing an individual’s subjective perception of physical, social, and psychological well-being, as well as satisfaction with the balance between disease control and adverse effects of treatment. There are generic and disease-specific instruments that can be used to measure quality of life. These instruments include SF-36, QLQ-C30, and QLQ-CR38 [9].

Elements of the CGA, especially comorbidity, functional status, frailty, and cognitive dysfunction, are consistently associated with adverse treatment outcomes such as toxicity and mortality.

It is beneficial for all older patients with cancer to receive a complete geriatric assessment. In fact, a meta-analysis by Ellis et al. in 2011 [3] has shown that patients who received a formal CGA in secondary care were more likely to be alive and in their own homes at 12 months follow-up. However, a complete CGA is time-consuming. Studies show that frailty screening methods are useful in the selection of those patients who will benefit from a complete CGA or further assessment. These frailty screening methods include:

1. Timed up and go. This test assesses mobility, balance, walking ability, and risk of falls in older adults. Patients, who require more than 10 seconds to perform the exercise, those who need to use their arms to get up, or those who perform an erroneous trajectory, will need a full CGA [8];

2. Seven-item physical performance. This test ‘assesses multiple domains of physical function using observed performance of tasks that simulate activities of daily living of various degrees of difficulty.’ This test takes 10 min to perform. If the total result is less than 20, a CGA would be beneficial. It has been demonstrated to be more sensitive than the Karnofsky performance status in recognizing patients with a higher risk of functional decline;

3. Vulnerable elders survey 13 (VES-13) [10]. This is a ‘simple function-based tool for screening community-dwelling populations to identify older persons at risk for health deterioration.’ Scores that are equal or above three indicate a higher risk of functional deterioration and a four-fold increased probability of death within the next 2 years. A complete CGA is then indicated [11, 12, 13, 14]. If the score is less than three, the patient can receive the standard treatment recommended for adult patients according to the tumor stage.

The concept of ‘frailty’ continues to develop and expand. Criteria used by Fried et al. [15] include an assessment of weight loss, physical exhaustion, physical activity level, grip strength, and speed of walking. Any degree of frailty measured by the Hopkins Frailty Score [16] has been linked to a worse postoperative outcome after surgery for colorectal cancer. Core features of frailty include impairments in multiple and interrelated systems, resulting in a reduced ability to tolerate stressful events. This is associated with an increase in vulnerability to severe complications with cancer treatment, which may then lead to an increase in overall mortality [17, 18].

Wieland and Hirth recommend that the CGA should include the following [19, 20]:

1. Functional status: Evaluation of dependency in daily activities using scales such as Barthel and Lawron, the TITAN scale, and the Karnofsky index. Functional decline in an elderly patient is a predictor of short- and medium-term mortality, independent of the disease process [21];

2. Comorbidity: The Charlson comorbidity index predicts 1-year mortality in patients with coexisting illnesses. Sarcopenia (skeletal muscle depletion) in older patients is related to infection, requirements for rehabilitation following surgery, and length of hospital stay;

3. Socio-economic evaluation: The elderly population is at a greater risk of social deprivation. The social situation of the older patient should, therefore, always be evaluated, and any cases of social isolation identified and dealt with through the social services;

4. Nutritional status: A useful tool is the mini nutritional assessment. Patients who are identified as being undernourished, with a recent loss of more than 5% weight or a body mass index less than 19, should be assessed and managed appropriately in conjunction with the dieticians;

5. Cognitive status: The mini-mental state examination is useful in this regard. The impact of depression and dementia on the treatment of colorectal cancer is not well known, but it has been identified as one of the determinant factors in receiving inadequate treatment;

6. Geriatric syndromes: The presence of geriatric syndromes, such as urinary and fecal incontinence and risk of falls, is an indicator of frailty [22]. A full assessment of the cognitive and emotional state is particularly important in older cancer patients. Polypharmacy, with the risk of drug interactions, is common in these patients;

7. Surgical risk: The American Society of Anesthesiologists (ASA) classification continues to be one of the most reliable predictors of postoperative morbidity and mortality. Multiple studies have shown that the presence of comorbidities increases the risk of postoperative complications, and this is more evident in patients over 70 years of age;

8. An evaluation of the patient’s views and expectations on the aims of treatment. The ideal treatment of the older adult patient with cancer starts with a careful delineation of goals through conversation. Studies show that older patients want to be informed about the diagnosis and prognosis of their disease [23, 24].

Multidisciplinary team working involves specialties such as oncologists, surgeons, gastroenterologists, radiotherapists, anesthetists, radiologists, and pathologists. This has become essential in the management of elderly patients with cancer. It is recommended that older patients with colorectal cancer should be treated in hospitals, where the expertise is available to provide the most favorable surgical and oncologic treatment outcomes.

Balducci [25] studied the role of CGA in the selection of treatment for cancer. Patients were placed into three groups depending on the severity of frailty symptoms and signs:

1. Functionally independent patients without any important comorbidities. These patients may be suitable to receive standard cancer-specific treatment such as surgery;

2. Functionally dependent patients with two or less comorbidities. These patients could benefit from a modified cancer-specific treatment such as a less extensive surgical resection, as for example a transanal resection of a rectal cancer instead of an anterior resection;

3. Partially dependent patients with three or more comorbidities or the presence of a geriatric syndrome. Palliative or best supportive care is usually recommended for these patients.

3. Outcome of elective surgery in the older patient

There is no consensus about the optimal surgical management of older people with colorectal cancer, whose fitness varies from very fit to very frail individuals. This population is undertreated compared with younger patients, with a comparatively lower percentage of patients being operated on. Older cancer patients are recruited less often to clinical trials than younger patients and are therefore under-represented in publications about cancer treatment [26].

Surgical risk stratification remains one of the most important aspects in the management of older patients [27]. Age is associated with an increased mortality following elective colorectal resection, with a mortality of up to 15.6% in patients who are older than 80 years of age. Patients with higher levels of comorbidities are expected to have significantly higher rates of complications, longer hospital stays, and mortality [28].

The American Society of Anaesthetists (ASA) score is the most commonly used parameter to compare comorbidities in younger and older patients. Whereas Vironen et al. [29] and Li et al., [30] concluded that there were multiple interobserver errors in computing the ASA scores, and therefore ASA scores were considered to be of limited in use for surgical patients, other studies concluded otherwise. Significant differences in the ASA scores between the younger and older groups were shown by Symeonidis et al. [31], Khan et al., [32], Marusch et al. [33], and Gurevitch et al. [34].

Symeonidis et al. showed that there was a significant difference in mortality rate for those having an ASA score of two or more when compared to those with a lower ASA score [31]. This paper also correlated an increased postoperative mortality rate to a higher TNM score. On the other hand, Vironen et al. [29] demonstrated that when comparing two groups over and under 75 years of age, but with similar ASA scores, there was no significant difference in postoperative mortality. In this case, the postoperative mortality rate was shown to be low throughout, no matter the ASA score. It seems that there was considerable interobserver inconsistency of classification, making the ASA score too imprecise to use with regards to making a treatment decision.

Schwandner et al. [35] included 298 patients who had undergone laparoscopic or laparoscopic-assisted procedures for colorectal surgery. The morbidity in patients above 70 years of age and that in patients below 70 years of age showed no statistically significant difference. Also, two patients above 70 years of age died versus one patient below that age. They concluded ‘if preoperative assessment of comorbid conditions and perioperative care was ensured, laparoscopic procedures were shown to be safe options in the elderly. The outcome of laparoscopic colorectal surgery in patients older than 70 years is similar to that noted in younger patients. Advanced age is no contraindication for laparoscopic colorectal surgery.’ Tan et al. [36] studied 727 patients with an age of 70 years and over who underwent laparoscopic and open colorectal cancer surgery. The 30-day mortality was significantly lower in the laparoscopic arm compared to open colectomy (1.3 vs. 4.6%). Laparoscopic colectomy was deemed safe in older patients and not associated with a higher morbidity.

Ong et al. [37] included 90 patients who were 80 years of age or older and who had undergone colorectal cancer surgery. A morbidity of 21% and a 30-day mortality of 1.1% were reported. Basili et al. [38] reported their experience with 248 patients who had undergone colorectal cancer surgery. Patients were divided into four age groups: less than 65 years, 66 to 74 years, 75 to 84 years, and more than 85 years of age. The 30-day mortalities were 0% for under 75 years of age, and 6% and 7%, respectively, for patients with ages from 75 to 84 years and those older than 85 years. However, none of these results was significant.

In a large multicenter prospective observational study in Germany on 16,142 patients who were younger than 80 years of age and 2932 who were 80 years of age or older, Marusch et al. [33] reported an overall morbidity of 35.4% with a significant difference (p < 0.001) between patients less than 80 years of age (33.9%) and those more than 80 years of age (43.5%). Significant differences were also found between the morbidity for emergency surgery (p < 0.001) and that for elective surgery (p < 0.001). The 30-day postoperative mortality rate also differed significantly (p < 0.001), 2.1% and 7.2% for those less than 80 years of age and those more than 80 years of age, respectively. Despite these significant results, they concluded that age alone should not be a limitation for surgery.

In a recent retrospective study by Shalaby et al. [39], the outcome of colorectal cancer surgery between two groups of patients was compared. The mean ages were 85 years in group A (range, 80 to 104 years) and 55.3 years in group B (range, 13 to 79 years). Both groups were manually matched for body mass index, ASA score, Charlson Comorbidity Index, and procedure performed. The overall 30-day postoperative mortality rate was 1% of total 200 patients, both of these two patients were in group A. However, this observation had no statistical significance. No intraoperative complications were encountered in either group. The 30-day postoperative morbidity rates in groups A and B were 28 and 26%, respectively. However, these differences between the groups were not statistically significant.

Marusch et al. [33] demonstrated a significant difference (p < 0.001) in the postoperative mortality rate between the groups (in this case, cohort 1 was under 65, cohort 2 was 65–79 and cohort 3 was over 80 years old). The differences were significant in both emergency (p = 0.004) and elective surgery (p < 0.001). The tumor stage differed significantly between the cohorts, which may be a reason for the increased mortality in the older age groups.

Andereggen et al. [40] demonstrated a postoperative mortality rate of 5% and a 67% 5-year survival, with 57% of deaths occurring in this period being unrelated to cancer. This was similar to the 60% 5-year survival shown by Vironen et al. [29]. Hermans et al. [41] demonstrated a mortality rate of 16% in those over 75 years and 5% in those under 75 years (p < 0.01), and between the two groups, there were no significant differences in comorbidities except for cardiovascular problems, which were more prevalent in the elderly group (p < 0.01, with 49% of all patients in the elderly group and 25% of all patients in the younger group having cardiovascular problems).

Gurevitch et al. [34] also found a significant difference in postoperative mortality between the younger and older groups (p < 0.01), though the cutoff age, in this case, was 80. In this study, emergency surgery was also considered, and there was a higher risk of postoperative mortality in the emergency setting (p < 0.001). Poor functional status, as well as the ASA score, was assessed in this case and there was a significant difference (p < 0.05) of 8% in the under 80 cohort and 32% in the over 80 cohort. Symeonidis et al. [31] showed that more elderly patients presented for emergency surgery when compared to younger patients (29.7 vs. 15.7%), p < 0.001). Hermans et al. [41] demonstrated a 22% emergency presentation in the over 75 age group and a 9% emergency presentation in the younger age group (p < 0.05) thus concurring with the conclusion of Symeonidis et al.. On the other hand, Khan et al. [32] noted that although 17.9% of the elderly group presented as an emergency when compared to 12.1% of the younger group, the difference was not significant (p = 0.25).

Leong et al. [42, 43] demonstrated increased morbidity and mortality rates following emergency surgery in the older colorectal cancer patients. The crude mortality rate was 27.5%. The most common cause of death was pneumonia, causing 38% of deaths. Other causes included sepsis and acute myocardial infarction, each causing 19% of deaths. A high ASA score was associated with a higher mortality (p = 0.04), and in this study, 52.5% of patients had an ASA score of III or IV. With regards to postoperative morbidity, 81% of total patients presented with postoperative complications. Pneumonia was once again the commonest complication (38%), followed by wound infection (16% of complications). Renal impairment, prolonged ileus, and fluid overload each caused 14% of total complications. In this study, it was also shown that Duke’s staging had no impact on the mortality (p = 0.48) or morbidity (p = 0.51).

Li et al. [30], using the Score of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), showed that ACPGBI scores showed a higher concordance between predicted probability of postoperative mortality and the actual postoperative outcome than ASA scores. Roscio et al. used the Charlson comorbidity index (CCI) where a score of more than three was associated with twice the mortality rate of those scoring less than three. Mamidanna et al. [44] found that there was a significant difference in the mortality rate between patients younger and older than 75 (p < 0.01), and the rate was related to the presence of comorbidities.

With regards to the incidence of local postoperative complications, such as surgical site infections, in the older patient, the overall incidence was similar to a younger age group. In fact, Khan et al. [32] showed that when comparing the incidence of local postoperative complications in elective surgery, there was no difference (p = 0.39). However, systemic complications were higher in the older age group (p < 0.05), and higher ASA scores, as well as the tumor site, had a predictive effect on postoperative complications. In fact, those with an ASA score of two or higher were 2.9 times more likely to have systemic complications (CI 1.30–6.25). Older patients have the same rate of postoperative complications as younger patients with similar clinical status. Symeonidis et al. [31] demonstrated that while elderly patients demonstrated an increased morbidity (p = 0.002), this was dependent on their previous health status as shown by the ASA score and tumor stage.

Vironen et al. [29] studied patients with ASA scores one or two and compared them with patients of ASA score three or four. The overall complication rate was not significantly different between these two groups (p = 0.07). They also found no significant difference in the complication rates between those under 75 and those older than 75 (p = 0.31) with similar ASA scores. On the other hand, Marusch et al. [33] found significant differences in risk factors between the cohorts (cohort 1 was under 65, cohort 2 was 65–79, and cohort 3 was over 80 years old) (p < 0.001) when it came to preoperative risk factors such as cardiovascular or pulmonary conditions, or diabetes mellitus. Intraoperative complication rates did not differ significantly between the cohorts, but they differed in the case of systemic complications. General complications following emergency surgery also differed between age groups (p = 0.002). Local postoperative complications, such as anastomotic leaks, wound infection, and postoperative ileus, were significantly different for both emergency (p = 0.006) and elective surgery (p < 0.001) between the age groups. Gurevitch et al. [34] also found that when considering general postoperative complications there were no significant differences between the age groups, though there were significant differences in the presence of comorbidities and ASA scores between the cohorts (both p = 0.0001). However, certain general complications, such as pulmonary, cardiovascular, and urinary tract infections, were more common in the elderly. This was also demonstrated by Hermans et al. [41], who recorded significantly higher rates of wound infections, cases of pneumonia, urinary tract infections, and electrolyte disturbances in the over 75 age group (p < 0.05). However, unlike the study conclusions of Gurevitch et al., Hermans et al. demonstrated a significant difference in complications between younger (32%) and older (50%) age groups (p < 0.01).

Law et al. [45] found that the complication rate following elective surgery did not differ significantly in older and younger patients (36.8 vs. 30.1%, p = 0.141), but the ASA score was related to the morbidity of patients (p = 0.042). The concomitant medical diseases were also highly related to the morbidity (p = 0.033). Jin et al. [46] also demonstrated a significant differences in ASA scores between patients over and under 75, with 42.7% of the younger age group with a score of 2 or more, and 77.8% of the older age group with an ASA score of 2 or more (p = 0.01). They also found a significant difference in the BMI, with younger patients having a higher BMI than older patients p = 0.035.

Older patients who are deemed to be clinically and biochemically optimized for surgery may still have poor outcomes. As discussed earlier, the concept of frailty can be used to identify patients who require further investigation before surgery. Patients with a high frailty score had a higher risk of developing major complications. Decreased survival in older (more than 75 years) patients after surgery has mainly been attributed to differences in early mortality [47, 48, 49]. The rate of cardiovascular complications increases significantly with age. Pulmonary complications are also twice as common. Postoperative complications are more severe in older patients [50, 51, 52, 53]. The occurrence of a complication was associated with a significantly increased risk of mortality at 6 months. Dekker et al. noted that the overall 6-month mortality was four times higher in older patients than in younger patients (14 vs. 3.3%; P < 0.0001) as was the 1-year mortality rate (20.1 vs. 5.1%) [54]. Older patients with colorectal cancer who survived the first postoperative year, however, had the same overall cancer-related survival as younger patients.

These results, therefore, confirm that the emphasis should be on survival and minimizing postoperative complications during the first postoperative year. These aims are achieved by the use of prehabilitation programs. These programs help correct malnutrition and optimize cardiovascular and pulmonary function [55].

4. Outcome of emergency surgery in the older patient

Emergency surgery should be avoided if possible. The presence of obstruction or perforation increases the perioperative mortality rate in older patients. Several studies show the correlation between advanced age, mortality, and emergent surgery. Kurian et al. [56] reported a postoperative 30-day mortality rate of 28% in emergency surgery compared to only 5% in elective surgery. Morse et al. [57] found similar outcomes in patients older than 80 years in open surgery for colonic cancer. Similarly, the results of the study by Louis et al. [58] found a close correlation between advanced age, high ASA grade, and emergency surgery. A study by Zerib et al. found that no patient with an ASA grade of three or more survived an emergency colectomy more than 6 months [59]. Modini et al. [60] reported a six-fold higher 30-day postoperative mortality in older patients more than 80 years of age when compared to younger patients. Basili et al. and McGillicuddy et al. noted that although morbidity and mortality rates in older patients could be similar to that of younger patients in elective surgery, these rates could be up to nine times higher in cases of emergency surgery [38, 61]. Patients over 70 years of age after emergency surgery have been shown to have a higher rate of postoperative myocardial infarction, and this complication is associated with a six-fold increase in postoperative mortality. Other common complications are pulmonary failure, acute renal failure, and sepsis; anastomotic leakage also occurred more frequently in older patients after emergency colorectal surgery and presented a significant association with postoperative mortality [62, 63, 64].

A feasible alternative management to emergency surgery for colonic obstruction could be the endoscopic placement of stents, especially in acute left-sided colonic obstruction. These self-expanding metallic stents alleviate obstruction and allow the clinician to optimize the patient’s clinical condition. In some cases, subsequent elective surgery may take place. Stents are, however, associated with a risk of colonic perforation and bleeding [65].

5. Outcome after laparoscopic surgery in the older patient

Laparoscopic surgery has been shown to reduce postoperative pain, allowing a decreased use of opioid analgesia, reducing postoperative ileus, and a reduced hospital stay [66]. In addition, laparoscopic surgery is beneficial to the older patient since it is associated with a reduced risk of cardiovascular and pulmonary complications, reduced intraoperative blood loss, and a quicker recovery of gastrointestinal function. For example, Chaudhary et al. demonstrated that elective laparoscopic surgery for colorectal cancer was associated with lower rates of pneumonia and cardiopulmonary complications when compared to open surgery [67]. Pinto et al. compared postoperative complications between groups of older patients, with similar ASA and BMI scores, having open and laparoscopic surgery. The laparotomy group had higher overall complication rates compared to the laparoscopic group (49.1 vs. 22.6%, p = 0.0007). The main differences were in the postoperative medical complications, with 38.8% of the laparotomy group and 21% of the laparoscopy group having medical complications (p = 0.01). Other complications, such as wound infections, anastomotic leaks, and deep vein thrombosis, were not significantly different between the two groups [68]. Stocchi et al. [69] found that the preoperative functional status of older patients following laparoscopic surgery was more frequently maintained at the time of discharge. In a randomized trial including 553 patients, Frasson et al. [66] had similarly concluded that laparoscopy should be the first choice in elderly patients operated on for CRC because it increases the preservation of functional status, allowing a higher rate of independence during the postoperative period and discharge and a faster postoperative recovery. Compared to open surgery, laparoscopic surgery is also beneficial to the older patient due to a lower inflammatory response and lower surgical stress.

6. Enhanced recovery after surgery (ERAS) programs for the older patients

Various studies have confirmed that older patients benefit from enhanced recovery after surgery (ERAS) programs in the same way as younger patients [70]. ERAS programs advocate the avoidance of bowel preparation, the restriction of opiate use, and early mobilization. The advantages of participation in an ERAS program are significant, with benefits noted primarily in the length of stay, readmission rates, and reoperation rates. Although overall complications are higher, there does not seem to be an increased risk of aspiration pneumonia in the older patient following early commencement of oral feeding.

7. Delayed discharge home after surgery for colorectal cancer

Delays in the discharge of older patients from the acute hospital may be attributed to various factors. A study from our institution by Pizzuto et al. noted ‘the reasons for delayed discharge of patients were due to social care issues, in particular, due to delays in transfer home because of the lack of a package of care or to a community hospital due to a lack of beds’ [71], even when the postoperative recovery of the older patient was uneventful. Pizzuto et al. and others advocate the early involvement of the local geriatric services in order to minimize avoidable acute hospital stays, a situation referred to as ‘bed blocking.’ Care of the elderly physicians may help by optimizing the medical management and addressing the psychosocial needs of these patients. Well-organized and coordinated hospital and community geriatric services, are therefore necessary to help improve outcomes such as survival and ensure that the older cancer patients recovering from cancer surgery reside in their own homes [72, 73].

Despite the aforementioned risks, some older patients do very well after curative surgery for colorectal cancer, but unfortunately, others will not [74, 75]. It is quite clear from the literature that the risks and benefits of surgery for CRC in the elderly have not been clearly reviewed [74]. There is, therefore, still no agreement on how actively the older patients should be treated and when not to offer them surgery, which could lead to physical disability and a worse quality of life. Over 74% of patients interviewed in a study by Ahmed et al. stated that they would refuse, or be reluctant, to receive treatment leading to severe functional impairment [75]. Therefore, the discussions with older patients and their significant others regarding treatment options should be made with careful consideration of life expectancy, morbidity and mortality, quality of life (physical, social, and psychological aspects), as well as the possibility of never returning home and needing permanent residential care.

8. Rectal cancer surgery in the older patients

The treatment of older patients with rectal cancer differs from that of colonic cancer, so it deserves a special mention. Surgery for rectal cancer takes longer to carry out than surgery for colonic cancer of a similar stage, thus increasing the risk of systemic complications. The risk of local complications after curative restorative surgery for rectal cancer, such as anastomotic leak, and pelvic abscess, is also higher than for colonic surgery. Therefore, in general, a more conservative approach in the treatment of rectal cancer in the older patient is preferred to more radical treatment in order to avoid high rates of postoperative morbidity [76].

The aim of rectal cancer surgery in older patients should be a reduction in local recurrence, as well as improvement in quality of life. Rather than age itself, the frailty of patients and preoperative sphincter function should determine the type of surgery for rectal cancer [77, 78]. Some older patients are keen to avoid a permanent stoma and may accept a higher risk of local recurrence to achieve this. However, sphincter preservation in older patients could result in poor functional results, especially in those with preexisting rectal and sphincter dysfunction. Studies have shown that older patients with the ‘anterior resection syndrome’ have a very poor quality of life. Patients with a risk of developing these functional bowel problems, following restorative rectal resection, should therefore be identified preoperatively and counseled appropriately on the construction of a stoma [79]. Although stomas are not without their problems, such as herniation and prolapse, a properly constructed stoma can lead to functional independence and enhanced quality of life.

Bhangu et al. [80] analyzed the results of local resection of rectal cancer in older patients, using techniques such as transanal resection of tumor (TART), transanal endoscopic microsurgery (TEMS), and transanal minimally invasive surgery (TAMIS). They showed that, in patients with pT1 tumors, local excision achieved the same results as radical surgery. However, in patients having local resection of pT2 cancers, the survival is less compared to radical surgery in the general population. The difference with the general population is most likely due to the prevalence of comorbidities in the older patient group, with the older patients not being fit for radical surgery or chemoradiotherapy. Transanal endoscopic surgery can, therefore, be considered as suitable palliative treatment option in such patients.

Chemoradiotherapy (CRT) or radiotherapy (RT) alone may be used instead of, or as an adjunct to, surgery for rectal cancer. Studies have shown that older patients with rectal cancer are treated less often with RT [81, 82, 83]. Fewer older patients are likely to receive preoperative RT with proportionately more receiving palliative RT instead [84]. Older patients with stage II or III rectal cancer who are fit enough for surgery are generally fit enough for preoperative neoadjuvant RT. Although the tolerability and response rates are similar to those seen in younger patients, Stockholm I and II trial results have shown the distinct side effects of neoadjuvant radiotherapy in older patients. Such side effects, which include deep vein thrombosis, femoral neck and pelvic ring fractures, small bowel obstruction, and fistulas, were significantly more prevalent after preoperative radiotherapy in the older age group [77, 81].

A number of patients who undergo neoadjuvant CRT have a complete pathological response. A complete pathological response means that there is no detectable residual rectal cancer on sigmoidoscopy or MRI. A strategy known as ‘watch and wait’ was proposed and pioneered by Habr-Gama et al. for these patients in order to spare them unnecessary resection [85]. They published a series of ‘watch and wait’ in 70 patients with tumor stages of pT2- and pN1-2 who were treated with CRT. Forty-seven patients had a complete clinical response, with 8 (17%) developing an early recurrence and four had a late recurrence. All had subsequent radical R0 surgery and were disease-free 56 months later. This could be an option for patients who are not considered fit for surgery. It does not have to be considered as a palliative treatment as such, but a possible standard treatment with a 50% probability of cure in frail elderly patients [80].

A study by Smith et al. [86] showed that older patients, because of their higher surgical risk, obtained the greatest benefit from the ‘watch and wait’ policy with an improved survival at 1 year after treatment. More recently, the results of a joint study between Glasgow University and Memorial Sloan Kettering in New York [87] concluded ‘a watch and wait strategy for select rectal cancer patients who had a clinical complete response after neoadjuvant therapy resulted in excellent rectal preservation and pelvic tumor control; however, in the watch and wait group, worse survival was noted along with a higher incidence of distant progression in patients with local regrowth vs those without local regrowth.’

The groups of patients that present a significant regression of their rectal cancer with neoadjuvant CRT, and especially those with lymph node regression (ypN0), could be candidates for alternative treatments without needing radical surgery. Transanal endoscopic surgical techniques could be used in these patients [80]. Local excision following CRT is associated with a 15% risk of recurrence. In older patient with comorbidities, such a risk may be an acceptable alternative to radical surgery [87, 88, 89, 90, 91].

9. Conclusion

The aim of surgery for colorectal cancer in the older patient is not only to optimize survival but also the improvement of quality of life and keeping postoperative complications to a minimum. Though some significant differences are present in postoperative morbidity and mortality rates between the young and old, chronological age alone should not be the deciding factor for surgery. Physiological rather than chronological age should determine the management of cancer in each individual, with due regard to comorbid illnesses. Therefore, risk stratification based on comorbidities, and biochemical and physiological markers could help to decide whether to perform surgery, what type of surgery, and the timing of surgery. Careful preoperative clinical assessment and prehabilitation programs are required in order to optimize outcomes. Laparoscopic surgical techniques should be employed whenever possible. Patients with rectal cancer benefit from transanal endoscopic surgery as a primary procedure or as part of a ‘watch and wait’ strategy following neoadjuvant chemoradiotherapy. Early elective surgery and the avoidance of emergency major surgery whenever possible, by for example the use of stenting followed by elective resection in cases of colonic obstruction, will help improve outcomes.

Author note

This chapter has been originally presented with the title “Surgery for colorectal cancer in the elderly: Is it safe”? at the Tripartite Colorectal Meeting of the American Society of Colon & Rectal Surgeons (ASCRS), Association of Coloproctology of Great Britain & Ireland (ACPGBI) and the Colorectal Surgical Society of Australia and New Zealand, in association with the European Society of Coloproctology (ESCP), 30th June to 3rd July 2014, Birmingham, UK.

It was published in abstract form in Colorectal Disease 2014, Vol.16, issue S2.