The United Kingdom National Bowel Cancer Project – Epidemiology and surgical risk in the elderly

doi:10.1016/j.ejca.2007.06.009

European Journal of Cancer

Volume 43, Issue 15, October 2007, Pages 2285-2294

https://doi.org/10.1016/j.ejca.2007.06.009 Get rights and content

Abstract

Objective

To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly.

Methods

Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest.

Results

Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes’ stage was lower. They underwent surgery less often (81% versus 88%, p < 0.001), but more frequently needed urgent or emergency procedures (p < 0.001) and non-excisional surgery (7.7% versus 6.6%, p < 0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p < 0.001), and their median length-of-stay was 2 days longer (p < 0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes’ stage A and D disease, but not for other subgroups.

Conclusion

Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.

Introduction

Colorectal cancer is among the most common malignancies in Europe,¹ and is the third most commonly diagnosed cancer and third leading cause of cancer-related deaths (for both genders) in the United States.² The incidence of colorectal cancer (CRC) increases with advancing age, with more than 90% of patients being diagnosed after the age of 55.³ As a result of an aging population in developed countries the management and outcome of CRC in the elderly population is becoming an increasingly important issue.

When assessed as a potential predictor of outcome, age has not been shown to have an effect on the long-term cancer-specific survival of patients with CRC.4, 5 However, post-operative morbidity and mortality following surgical resection for CRC have been shown to be significantly higher in those over 70 years of age compared with younger patients.⁶ In another study, in-hospital mortality for patients over 85 years of age was shown to be nine-times as high as that for those aged 65 and under.⁷ Additional factors that were previously identified to have significant bearing on colorectal cancer mortality include American Society of Anesthesiology (ASA) grade, operative urgency (emergency or elective), metastatic disease, no cancer excision versus resection,⁸ existing chronic obstructive airway disease and past history of thromboembolic disease.⁹

Survival is frequently considered to be the most important end-point of studies addressing patients with CRC.¹⁰ However, functional results after surgery, as well as quality of life (QoL) have gained prominence in recent years. Many studies have suggested that the QoL of stoma patients is worse than that for non-stoma patients,11, 12 while others suggested the converse to be true13, 14 or identified no difference.15, 16 The nature of the operative procedure performed may therefore be important in QoL, as well as oncological in terms.

The purpose of the present study was to examine the epidemiology and risk of surgery for elderly patients undergoing colorectal surgery by reviewing data over a five-year period across hospitals in Great Britain and Ireland.

Section snippets

Data source

Data on newly diagnosed patients with colorectal cancer were extracted from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising information from patients with bowel cancer diagnosed between March 31st, 2000 and April 1st, 2005. Participation in this multicentre study was voluntary and its conduct has been described previously.¹⁷ Data were collected locally by data managers dedicated to colorectal cancer or by participating surgeons, using

Results

There were 47,455 patients extracted from the ACPGBI colorectal cancer database diagnosed with colorectal cancer between April 2000 and March 2005. Of these 21,030 (44%) were aged 75 or above. The rate of patients undergoing surgery of any kind for their cancer was significantly higher for patients below 75 compared to those aged 75 and above (88% versus 81%, p < 0.001). Overall 40,349 patients (85%) underwent surgery. Further analysis considered only those patients undergoing surgery for

Discussion

In examining 47,455 patients over a 5-year period, this study has illustrated how patients aged 75 and older were less likely to undergo surgery at all, and excision of the primary tumour in particular, compared with their younger counterparts. A greater number of the elderly patients were classified ASA III or IV. The stage of disease was also lower compared with younger patients, with Dukes’ A and B tumours making up the majority of resections. This is likely to reflect a selection process,

Conclusion

Elderly patients are less likely to undergo major surgery for colorectal cancer, especially if they are male. In over-75s, Dukes’ C and D cancers are less likely to be resected, and more likely to undergo emergency surgery. More Hartmann’s procedures are performed in over-75s than in younger patients. The 30-day mortality in patients over 75 being three times as high. Although this study did not contain long-term survival data, the review of the literature suggests no difference in

Conflict of interest statement

None declared.

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The United Kingdom National Bowel Cancer Project – Epidemiology and surgical risk in the elderly

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Data source

Results

Discussion

Conclusion

Conflict of interest statement

Lancet

Eur J Cancer

Ann Oncol

Eur J Surg Oncol

Surg Oncol

Prognosis of elderly patients with large bowel cancer

Br J Surg

Favorable short-term and long-term outcome after elective radical rectal cancer resection in patients 75 years of age or older

Dis Colon Rectum

Assessment of operative risk in colorectal cancer surgery: the Cleveland Clinic Foundation colorectal cancer model

Dis Colon Rectum

Prediction of postoperative mortality in elderly patients with colorectal cancer

Dis Colon Rectum

Which comorbid conditions predict complications after surgery for colorectal cancer?

World J Surg

Quality of life in colorectal cancer. Stoma vs. nonstoma patients

Dis Colon Rectum

Quality of life in rectal cancer patients: a four-year prospective study

Ann Surg

Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer

Ann Surg

Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation

Dis Colon Rectum

Quality of life in survivors of colorectal carcinoma

Cancer

Quality of life among disease-free survivors of rectal cancer

J Clin Oncol

Operative mortality in colorectal cancer: prospective national study

BMJ

The role of anesthesia in surgical mortality

JAMA

Cancer of the colon: the influence of the no-touch isolation technique on survival rates

Ann Surg

Abdominoperineal resection via total mesorectal excision and autonomic nerve preservation for low rectal cancer

World J Surg

Local recurrence following total mesorectal excision for rectal cancer

Br J Surg

Development of a dedicated risk-adjustment scoring system for colorectal surgery (colorectal POSSUM)

Br J Surg

Are survival rates different for young and older patients with rectal cancer?

Dis Colon Rectum