Old age no barrier to rectal resection

Advanced age alone should not rule out curative resection for rectal cancer, say the authors of a systematic review.

"Comorbidity, rather than age, increases mortality and the occurrence of complications after curative surgery for rectal cancer in elderly patients," say Mehdi Karoui (Pierre and Marie Curie University, Paris, France) and colleagues.

"The frailty of patients and preoperative anal sphincter function determine the operative indication and type of surgery."

The authors, reporting in The Lancet Oncology, reviewed 48 studies published between January 1985 and April 2012 on the outcomes of curative rectal cancer surgery in patients aged over 70 years.

They found that 30-day mortality was significantly higher in patients aged over 75 years than in younger patients. However, older patients had significantly more comorbidities prior to surgery than younger patients.

Postoperative morbidity was similar between the two age groups but in elderly patients was associated with pre-existing comorbidities. Meanwhile, rates of complications were similar across age groups but they were more likely to be severe in elderly patients.

Overall 5-year survival was significantly lower in elderly patients compared with younger patients. However, a large retrospective study showed that cancer-specific survival has improved over recent years, and patients older than 75 years have comparable 5-year cancer-specific survival to younger patients (78.4 vs 80.1%).

The authors also report that, while physical, cognitive, and social functions were affected more in elderly patients, their overall quality of life after surgery did not differ from that of younger patients.

The authors say that careful preassessment of patients is needed to determine whether surgery is appropriate. In particular, assessment of sphincter function should be used to decide whether sphincter-saving surgery should be favored.

"Despite higher postoperative mortality and reduced overall survival, selected elderly patients benefit from radical surgery for rectal cancer," they write.

Karoui and colleagues say their review has highlighted a dearth of research on the outcomes of rectal surgery in older patients and that more studies are needed.

"In particular, these studies should raise the question of the most suitable type of diverting stoma for this population, and the extension of indications for local excision (with or without neoadjuvant or adjuvant chemoradiotherapy) for patients with significant comorbidities," they conclude.

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