In the next 50 years, the number of Americans older than 65 is expected to double from 35 million to 70 million. Because the incidence of cancer increases exponentially with advancing age, there will be a significant rise in the number of elderly patients diagnosed with cancer. It is projected that by the year 2050, the number of cancers in the elderly will reach 2.6 million. Currently, people older than 65 account for 60% of newly diagnosed malignancies and 70% of all cancer deaths.
Knowing that the life expectancy of a girl born in 2005 is 80.4 years, that for a boy it is 75.2 years, and that life expectancies of a 75-year-old woman and man are 12.8 and 10.8 years, respectively, should lead the cancer surgeon to be appropriately aggressive in the endeavor for 5-year survival in the elderly cancer patient.
Because surgery is the mainstay of treatment for solid tumors, the greatest dilemma for the oncologic surgeon is whether the use of radical surgery, with its accompanying morbidities, is justified in the very elderly. With advances in modern medicine, it is understood that any patient up to age 70 is eligible for the same degree of surgical intervention as a younger patient would be, unless the patient has very severe comorbidities. This chapter is dedicated to the discussion of treatment strategies for the patient age 70 or older. Unfortunately, scientific data from randomized studies is often not readily available for older populations because they are more likely to be excluded from clinical trials. Studies that are available are retrospective and often display considerable bias in the patients chosen for certain treatments, especially surgical procedures. Prejudices can arise from what is perceived as limited life expectancy, the presence of comorbid diseases, assumed decreased functional or mental status, limitations in economic resources, and assumed inability to tolerate treatment. The influences of these biases have affected the enrollment of patients into protocols and the treatment, and probably the survival, of elderly patients with cancer.
A study evaluating survival up to 10 years after the diagnosis of cancer in patients older than 65 years with various cancers revealed that not receiving definitive therapy for the patient’s cancer was associated with a threefold greater death rate. Inadequate treatment remained a significant factor, even after controlling for stage at diagnosis, socioeconomic factors, comorbidity, and physical functioning. Thus the evidence suggests that the withholding of appropriate treatment because of age will result in inferior survival.
The idea that the elderly, as a group, cannot tolerate extensive surgery has not been supported by the data. Over the past 30 years numerous publications have shown that surgical procedures can be performed safely in the elderly. The balance between operative risk and expected cure or palliation is important when treating any patient with cancer. The elderly patient’s age alone should not be an automatic contraindication to extensive surgery. The impact of treatment on the quality of life is extremely important and should always be kept in mind.
Data supports the rule that surgical morbidity and mortality rise with advanced disease states and emergency surgery. Because there is often a delay in cancer diagnosis in elderly patients, this can lead to more advanced cancers and a greater number of emergency presentations with the associated worse outcomes. Thus early diagnosis and treatment in the elderly should be encouraged. Not performing surgery in the elective setting may result in the same patient’s need for life-saving emergency surgery several months later.
This chapter reviews the role of surgery in the management of elderly patients with the following common solid organ cancers: (1) breast cancer; (2) colon cancer; (3) liver metastases; (4) gastric cancer; (5) pancreatic cancer; (6) melanoma.
Breast Cancer
A 79-year-old woman presented to her physician with a large palpable breast mass. She had a past medical history of congestive heart failure, poorly-controlled hypertension, poorly-controlled diabetes, morbid obesity, and bipolar disorder. She was a widow and lived by herself. Because of her significant comorbidities and the perceived risk of general anesthesia, she underwent a lumpectomy and sentinel lymph node biopsy under local anesthesia. Her pathology revealed a T3 lesion, 6 cm in size with clear margins and negative sentinel lymph node. The tumor was positive for both estrogen receptor (ER) and progesterone receptor (PR) and negative for HER-2/neu. After recovering from her surgery, the patient was able to receive standard postlumpectomy radiation by having transportation arranged for her by social services. She remains disease-free at this time on daily tamoxifen.
This case illustrates several points about breast cancer in the very elderly. Patients are often not screened after the age of 75 and can present with very large and sometime locally advanced cancers, like this woman. There are many elderly who are actually too frail to receive general anesthesia, yet for breast cancer these procedures can be done safely under local anesthesia. With the proper transportation support, the elderly, even those who live alone, can receive appropriate radiation. Tumors are overwhelmingly hormone-positive and hormonal therapy can be given safely to most of these patients.
The incidence of breast cancer rises with age. Nearly one third of breast cancers occur in women older than 70 years and half the deaths are in women older than 65 years of age.
Should the surgical treatment of breast cancer in the elderly be different than for younger women? Although the morbidity and mortality for breast surgery in the elderly is very low, the fear of treatment morbidity and mortality sometimes prompts a minimalist approach in the elderly, whereas, paradoxically, at other times, mastectomy is offered with little if any discussion about the possible desire for breast conservation. In addition, reconstruction is rarely offered to elderly patients.
Despite the fact that the National Institutes of Health consensus conference found breast-conserving therapy (BCT) to be the preferable method of treating early-stage disease it is still underutilized for all ages and particularly in the elderly. The elderly have also been found to have a lower rate of BCT in the treatment of ductal carcinoma in situ (DCIS).
Hurria et al. performed a retrospective study examining the factors influencing treatment patterns for women aged 75 and older with breast cancer. The goal of the study was to determine local and systemic treatment patterns for these patients. Even in this advanced age cohort, there was a difference in treatment seen between those patients aged 75 to 79 and those who were older. However, there was no difference in receiving hormonal therapy, which is generally viewed as a “less-toxic” treatment. Chemotherapy, radiation therapy, and axillary lymph node dissection, which are generally viewed as more “toxic” therapies were less likely to be used in the armamentarium for patients older than 80.
Patients with increased comorbidities were significantly less likely to receive radiation therapy, despite the findings of the Cancer and Leukemia Group B (CALGB) study that radiation is beneficial in preventing locoregional disease in women, age 70 and older, who have undergone partial mastectomy. Other studies have also demonstrated that when breast conservation is performed, it is often done without axillary dissection or the use of postoperative radiation, as would be the standard for younger women. In one retrospective series, the survival of elderly women was found to be lower for those treated with less-than-standard protocols.
The relatively recent implementation of sentinel lymph node (SLN) biopsy instead of a full axillary dissection has resulted in decreased operative morbidity. Overall, SLN biopsy has been shown to be a safe procedure, with accuracies of 97% in randomized studies of all age groups. Looking specifically at the older patient, one series of 241 patients 70 years or older identified the SLN in every one, with no major complications. Another study of 730 breast cancer patients compared the rate of identification of SLN in the younger patients and the 261 (36%) patients who were at least 70 years of age. The overall sentinel node identification rate was statistically equivalent in the group younger than 70 (98.8%) versus the older group (97.1%). These kinds of data support the dictum that SLN biopsy should be offered to all women diagnosed with invasive breast cancer who do not have palpable axillary disease, regardless of age. The combination of lumpectomy with SLN biopsy, which is now considered the standard of care, can be done as an outpatient procedure with limited if any morbidity and there should be no reason to deny this definitive treatment to the elderly.
Radiation therapy to the breast after BCT is considered standard therapy, yet radiation is often omitted in many elderly patients. In one series, only 41% of women older than 75 years had radiation, in contrast to 90% of women younger than 65 years and 86% of women between the ages of 65 and 74 years. Concerns have been expressed about whether the elderly will tolerate radiation, whether they will have difficulty completing therapy because of physical restraints in getting to radiation facilities, and whether long-term outcomes are the same as in younger patients. However, many studies have provided evidence to refute these concerns. Furthermore, studies show that local recurrence rates for breast cancer have been reported as high as 35% in the elderly when radiation is not given, contradicting the theory that those patients will not benefit from radiation therapy. A randomized study from the CALGB compared 647 women older than 70 years with stage I estrogen-positive breast cancer that were randomized to receive lumpectomy plus tamoxifen or lumpectomy followed by tamoxifen and radiation therapy. The group given radiation had a significantly lower risk of locoregional recurrence (1% versus 7%; p<0.001) at a median follow-up of 7.9 years. Surgeons who believe that radiation therapy is not possible in the elderly will not offer them the choice of lumpectomy, moving straight to mastectomy. Again, evidence has shown that this is not the correct way to treat these elderly patients, who should have the same choice for breast-conserving therapy as younger patients.
In the elderly patient who undergoes a mastectomy, very rarely is breast reconstruction performed or even offered. In one study, the single greatest predictor for a surgeon to recommend breast reconstruction was patient age younger than 50. Yet experience with breast reconstruction in patients older than 60 demonstrates that it is safe, provides good long-standing results, and has acceptable complication rates when compared to younger patients. Age alone should not be a determining factor in selecting women for breast reconstruction, but this should be a discussion between the patient and physician.
In summary, surgical treatment of breast cancer in the elderly should follow the standard of care used for all women. Breast-conserving surgery and SLN biopsy with radiation has been shown to be safe and effective in treating breast cancer, with low morbidity and mortality in all age groups.
Colon Cancer
A 77-year old- man presented to the emergency department with acute onset of abdominal pain. A CT scan revealed a partial small bowel obstruction with a cecal mass. The patient had never had a colonoscopy and was not followed by a primary care physician. On follow-up abdominal films the next day, the oral contrast from the CT scan was noted in the left colon. Thus after a bowel prep, a colonoscopy revealed a near-obstructing large cecal adenocarcinoma. He was taken to the OR on the next day for a right hemicolectomy. Pathology showed a T3N2 (12/25LN+) stage IIIC colon cancer. Postoperatively, an abdominal fluid collection in the right lower quadrant developed, which required drainage by interventional radiology. After drainage, he did well. He received adjuvant chemotherapy, is doing well more than 1 year postoperatively, and is free of disease on radiographic studies.
This case illustrates three points about colon cancer in the elderly: (1) right-sided lesions are more common; (2) lesions are detected at more advanced stages; (3) emergency operations are often necessary at presentation, with increased morbidity.
The incidence of colorectal cancer increases with age, as 90% of patients are diagnosed after age 55. Several studies report a difference in tumor location between the more elderly and the younger patients, with more right-sided lesions and fewer rectal lesions in the elderly. Because patients with right-sided lesions are more likely to present later, due to fewer signs and symptoms compared to left-sided or rectal cancers, the older patients are more likely to fall into the late presentation category.
Several studies show that elderly patients are more likely to undergo emergency surgical procedures compared to a younger population. In one study from the British Colorectal Cancer Collaborative Group (CCCG), the incidence of undergoing an emergency operation more than doubled for patients 85 or older (11% for younger than 65 years vs. 29% for 85 years or older, p<0.0001). The same study also revealed differences in both stage at presentation and the rate of curative surgery within the elderly population, with the “older of the old” presenting with more advanced disease and being less likely to undergo curative surgery.
Because of recent data from a number of studies demonstrating improved survival when at least 12 lymph nodes are examined in resection specimens for colon cancer, this number is now considered the gold standard for node removal. The data revealed a benefit in resecting at least 12 lymph nodes irrespective of the patient’s age. The adequacy of number of lymph nodes removed in elderly patients was recently examined, revealing that as age increased the number of nodes removed decreased. This might reflect a less extensive operation, possibly accounting for decreased survival in the elderly.
The mainstay of curative therapy for all nonmetastatic colon cancer is adequate surgical resection. It may even be required in many cases in the presence of disseminated disease to avoid or treat the complications of obstruction and bleeding. A number of retrospective series examined the influence of advanced age on the morbidity of colon cancer surgery. The risk of perioperative complications is generally reported to be higher in the elderly than in younger patients. In a meta-analysis, the cardiovascular complications were statistically significantly increased (p<0.001) in one series from 0.8% in patients older than 65 to 4% in patients older than 75. Pneumonia and respiratory failure was seen in 5% of patients younger than 65 years, compared to 15% in those at least age 85 (p<0.001). However, the anastomotic leak rates in the meta-analysis were not statistically different in young versus elderly patients. A large study from the United Kingdom of more than 2500 patients 80 years old or older showed an increased mortality, but colectomy-specific complications, such as anastomotic leaks, were no different in the elderly versus younger patients. The 30-day overall mortality rate was 15.6%, but increased to 27.5% for those at least age 95. Multivariate analysis for this group of very elderly patients revealed the following independent risk factors for 30-day mortality: age; operative urgency; ASA grade; resection versus no resection; metastatic disease. Other studies support these conclusions that comorbid factors in the very elderly may increase multisystem-related complications, which are further exaggerated in the emergent situation, but there is no increase of anastomotic leaks due to advanced age.
Emergency operations are clearly associated with an increased mortality rate. Elderly patients presenting with malignant bowel obstructions are a high-risk cohort with increased postoperative complications and mortality. In the previously mentioned British study, approximately 25% of patients that underwent either a palliative stoma or a Hartmann procedure died within 30 days postoperatively. These procedures are often done as an emergency in an end-stage patient, two factors known to contribute to an increased risk of morbidity and mortality. Early intervention with semi-elective surgery would often avoid situations such as bleeding, perforation, and obstruction that require emergency surgical intervention.
Overall cancer-related survival was comparable when comparing patients aged 75 and older to those under 75, despite an increase in operative mortality for the older population. One study showed that although the physical status and operative mortality were worse in the elderly undergoing surgery for colorectal cancer, for those elderly who were fit for surgery, who underwent curative resection, and who survived more than 30 days, the 5-year survival was comparable to younger patients by multivariate analysis.
Age alone should never be a contraindication for colectomy, and whenever possible, the full curative treatment including adjuvant chemotherapy should be utilized as indicated by pathologic and operative findings.
Liver Metastases from Colon Cancer
An 85-year-old man who had a colon resection for a stage III colon cancer 7 years prior was noted on routine blood work to have an elevated CEA level at 7.1 ng/mL (normal <2.5). A CT scan showed a solitary lesion in the left lobe of the liver. These findings were confirmed by PET scan which revealed only the lesion in the left lobe of the liver. Treatment options were discussed with the patient and he opted to undergo a liver resection, a left lateral lobectomy. The patient required no blood transfusions. He was discharged home 5 days after surgery and has done well since.
Metastatic disease from colorectal cancer is predominantly (80%) found in the liver and often confined to the liver on presentation. For patients with liver-only disease that is deemed operable, liver resection can lead to a 21% to 48% 5-year survival. The safety of performing liver resections has greatly improved in recent years owing to improvements in techniques of resection and intraoperative and postoperative care. Liver resections are now being routinely performed with mortality rates of less than 5%.
Liver resections can also be performed safely in elderly patients. A number of series have looked at morbidity and mortality rates for older individuals. A study from Memorial Sloan-Kettering Cancer Center reviewing liver resections for colorectal metastases in 128 patients older than 70 found the perioperative mortality rate and the morbidity rate were the same as for patients younger than 70. In multivariate analysis, the three factors that were found to be important in predicting complications (male sex, resection of at least one lobe of the liver, and an operating time of greater than 4 hours) did not include age. Median hospital stay for patients aged 70 years and older was only 1 day longer than for patients younger than 70 years.
There are several prognostic scoring systems to estimate the prognosis after liver resection, and none of them has age as one of the significant prognostic variables. When deciding on the usefulness of a liver resection in an elderly patient one of these systems should be employed. The clinical risk score devised by Memorial Sloan-Kettering used 5 factors to compute survival. They were: (1) nodal status of primary disease; (2) disease-free interval of less than 12 months between primary and metastases; (3) more than one hepatic tumor; (4) CEA level greater than 200 ng/mL; and (5) size of metastases greater than 5 cm. If all of the factors are good, then the projected 5-year survival is 60%. If a patient has all the negative factors, the survival drops to 14%. Another scoring system from France uses seven variables ( Table 6-1 ) and computes 2-year survival. These systems should be used for all patients, including the elderly, because elderly patients can benefit from liver resection equally to younger patients.
| Variable | Zero Points | One Point |
|---|---|---|
| Age | ≤60 | >60 |
| Tumor size | <5 cm | ≥5 cm |
| Nodal involvement of primary tumor | No | Yes |
| Disease-free interval | ≥2 years | <2 years |
| Number of liver lesions | <4 | ≥4 |
| Resection margins | Negative | Positive |
| CEA level | <5 | ≥30 |
| Total Points | Survival Rate | |
| 2-year survival | 0-2 | 79% |
| 3-4 | 0% | |
| 5-7 | 43% |
Gastric Cancer
A 76-year-old man with a history of alcohol and tobacco abuse reported dark tarry stools and was noted by his primary care physician to be anemic. He underwent upper and lower enodoscopy and was noted to have a large ulcer along the greater curvature of the stomach. A biopsy was performed, which revealed adenocarcinoma. The patient reported neither weight loss nor early satiety. He had a history of diabetes mellitus, hypertension, and obesity. A metastatic workup was negative, and the patient underwent a total gastrectomy with a D2 lymphadenectomy with Roux-en-Y esophagojejunostomy reconstruction. He recovered well and was discharged home 1 week postoperatively. Within a month of his surgery, he started chemoradiotherapy for his Stage II (T2bN1) gastric cancer.
Gastric cancer rates have been declining over the past 75 years in the United States , but the prognosis has not improved, with 5-year survival being 20% to 40%. Despite the fact that the incidence of the disease has fallen in the past 75 years, the number of patients diagnosed at 75 years or older is actually increasing. Gastric cancer in the United States is generally seen in the elderly, with nearly 50% of cases in males and 60% of those in females being in patients older than 70 years. Surgery is the only curative modality available for gastric cancer. Palliative surgery is often needed for bleeding and obstruction. An important element in deciding about gastrectomy in the elderly is the impact on the quality of life. A study that addressed this question in a small series of patients older than 70 years undergoing total gastrectomy showed that 70% of patients returned to “normal life” after 1 year.
In Asia, where gastric cancer is much more common, many investigators have examined the characteristics of gastric cancer in the elderly. Symptoms at presentation and location of disease in the stomach have been found to be similar in younger and older patients. Also, studies have shown no difference with age in the incidence of lymph node metastases and stage at diagnosis, with most patients having T3 and T4 disease at the time of exploration.
Curative surgery for gastric cancer requires either a subtotal or a total gastrectomy depending on the location and size of the tumor. The exact extent of lymph node dissection necessary remains a controversial subject, yet most surgical oncologists perform at least a D2 resection. There have been a number of reports on the morbidity and mortality rates of gastric resections in the elderly ( Table 6-2 ). Although preoperative risk factors, particularly cardiac and pulmonary, are increased in the elderly with gastric cancer, most complications and deaths are caused by infections, anastomotic leaks, and pulmonary problems just as in younger patients. A large study from Italy reviewing gastric resections for gastric cancer over a 15-year period reported that the overall postoperative surgical complication rate was 20% in the elderly group (age 75 and older) versus 17% in the younger. The postoperative mortality rate for both groups was 3%. Multivariate analysis revealed that age was not a risk factor for either postoperative morbidity or mortality.
| Reference (Year) | Country | Age | Number of Patients | Morbidity (%) | Mortality (%) |
|---|---|---|---|---|---|
| Wu (2000) | Taiwan | ≥65 | 433 | 21.7 | 5.1 |
| Saidi (2004) | US | ≥70 | 24 | 33.3 | 8.33 |
| Mochiki (2005) | Japan |
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| Kunisaki (2006) | Japan | ≥75 | 117 | 29 | 0.85 |
| Gretschel (2006) | Germany | >75 | 48 | 48 | 8 |
| Orsenigo (2007) | Italy | ≥75 | 249 | 29 | 3 |
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