Abstract
SAN FRANCISCO: As people are living longer, more elderly patients are being diagnosed with age-related colon cancer, making it of increasing concern to the medical community. Another related issue is whether an operation should be suggested as a form of treatment for this vulnerable population.
However, results from a preliminary research study reveal the vast majority of surgical patients over 85 were still alive in the short-term after undergoing an operation (called colectomy) to remove a portion of the colon for stage II and III colon cancer. Researchers presented their findings at the American College of Surgeons Clinical Congress 2019.
Using the New York State Cancer Registry and Statewide Planning Research & Cooperative System, lead study author Roma Kaur, MD, a research fellow in the department of surgery, University of Rochester Medical Center, N.Y. and colleagues analyzed data on 3,779 patients age 85 and older who underwent colectomy between 2004 and 2012. They looked at short-term outcomes (30 and 90 day) among patients with Stage II or Stage III colon cancer.
"We were interested in this topic because we know from CDC data that patients 85 and older have the highest incidence rate of colon cancer and according to the U.S. Census Bureau this is the fastest growing segment of the geriatric population. Given the burden of colon cancer in this cohort, we were hoping to identify and better understand factors that were associated with survival in these patients," said Dr. Kaur.
The survival rates of all patients were evaluated from the time of the operation. After 30 days, 89 percent of patients were alive, and after 90 days, 83 percent of patients were still alive. Factors associated with worse survival were having an operation during an unplanned admission, having an open operation, and preoperative complications like perforation, bleeding, and a serious infection called sepsis.
There were several noteworthy findings in the study. Nearly half of the patients received a diagnosis of colon cancer and surgery performed during an unplanned hospital admission, a factor found to be independently associated with worse survival. Additionally, the study suggested being treated by an experienced surgeon who performs a large number of colon cancer resection procedures annually reduced the risk of dying in this population.
Regarding the number of non-elective procedures, Dr. Kaur said, "It seems a large number of patients are coming into the hospital with a problem that is severe enough to require admission—sometimes a complication from their cancer—and then getting diagnosed with cancer and undergoing an operation during that same hospitalization. We found that 80 percent had an open operation, as opposed to a minimally invasive one, so these patients are being subjected to open operations because, in part, it's taking place in an acute setting."
During an open operation a surgeon makes a larger incision; whereas, for a minimally invasive operation, a few small incisions are made, and surgeons use laparoscopic instruments to perform the procedure. Generally, minimally invasive surgery is favored due to outcomes like less pain, shorter hospital stays, and faster recovery times.
"When patients have surgery in a nonelective setting it makes it nearly impossible for these patients to be adequately optimized before their operation. If we are able to find these patients earlier, we may be able to do a comprehensive geriatric assessment, prehabilitation before surgery, and perhaps even a minimally invasive operation," Dr. Kaur added.
While colonoscopy is considered a gold standard procedure for preventing death from colon cancer, screening older adults is controversial. According to the U.S. Preventive Services Task Force, adults age 76 to 85 should consult with their doctor before getting this diagnostic test.* Results from the study corroborate the idea that perhaps screening guidelines should not be solely based on chronological age, but rather be more individualized, and incorporate the patient's life expectancy, health status, and ability to tolerate the screening procedure into account. The role of less invasive screening alternatives and identifying the "right" patients to screen will require further study, according to the researchers.
To improve care among older adults, factors yielding favorable outcomes need to be identified. This study found that two factors—discharge to another health care setting and higher surgeon colon cancer resection volume—were associated with improved survival.
"Postoperatively, we need to consider the full breadth of resources available to patients—physical and occupational therapy needs, nursing needs, and to evaluate if they would benefit from being discharged to another health care facility," said Dr. Kaur.
About 42 percent of these patients were discharged to a skilled nursing facility after their operation. The move reduced the odds of dying by 89 percent at 30 days, and by 58 percent at 90 days.
When the the operation was performed by a highly experienced surgeon, it also reduced the risk of death. The researchers reported a nearly 59 percent reduction in the odds of mortality in the short-term associated with surgeons who performed a higher volume of colon resection procedures per year.
"The decision to operate on an older adult must take many factors into account," Dr. Kaur said.
Study coauthors are Christopher T. Aquina, MD, MPH; Larissa K. Temple, MD, FACS; and Fergal Fleming, MD.
"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.
* Colorectal Cancer: Screening. U.S. Preventive Services Task Force. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/colorectal-cancer-screening2. Accessed October 21, 2019.
