Advanced Age and Gastroesophageal Cancer Surgery
Advanced Age and Gastroesophageal Cancer Surgery
Abstract & Commentary
By William B. Ershler, MD
Synopsis: In a series of 600 consecutive patients with gastroesophageal cancer, older patient age was associated with more frequent surgical complications and shorter overall survival.
Source: Braiteh F, et al. Association of age and survival in patients with gastroesophageal cancer undergoing surgery with or without preoperative therapy. Cancer. 2009;115:4450-4458.
Gastroesophageal cancer occurs most commonly in patients older than 65 years, with only 15% occurring in those younger than 55 years. Surgery remains the primary therapeutic modality, either alone or after radiation or chemotherapy.1 However, the question of whether advanced patient age compromises surgical outcomes needs to be established. In a comprehensive report from Japan, it appeared that older patients suffered greater morbidity and mortality than their younger cohorts.2 In contrast, Lagarde et al, in an extensive review of prognostic factors, found no significant effect of host age.3 Thus, Braiteh et al from M.D. Anderson Cancer Center reviewed the records of patients operated on at their institution between the years 1998 and 2007, either with or without prior radiation and/or chemotherapy. The purpose of this retrospective analysis was to determine the incidence of surgical complications and mortality in the context of patient age.
Six hundred consecutive patients with esophageal cancer who underwent surgery (409 patients received preoperative therapy and 191 patients underwent surgery first) were analyzed. All demographic information (including American Society of Anesthesiology risk scores) and therapy-related information was catalogued for review. Multiple statistical methods were employed to assess survival rates and surgical complications and their correlation with patient age. Twenty-one patients (30-day mortality) first were excluded (n = 600) and then were included (n = 621) in the analysis.
By using the median age (≤ 60 years) as the cut-off point, and creating two subgroups (ages 61 years to 70 years and aged > 70 years) in patients older than the median age, univariate analysis demonstrated a higher risk of death with increasing age (p = .019). In multivariate analysis, increasing age was an independent indicator of poor overall survival (p = .041). The inclusion of those individuals who died within 30 days after surgery did not alter the results. Surgical complications were statistically significantly higher in older patients compared with younger patients in the following categories: aspiration pneumonia, adult respiratory distress syndrome, cardiovascular, neurologic, and miscellaneous complications.
The data in this study demonstrated that patients aged 60 years and younger who underwent surgery for esophageal cancer achieved the best overall survival and experienced fewer surgical complications than patients aged > 70 years.
Commentary
It is well established that cancer occurs primarily in elderly patients, with approximately two-thirds of cancer-related death in those > 60 years and 25% in patients older than 80 years. Esophageal cancer is the eighth most common cancer and the sixth cause of cancer mortality worldwide,4 with well over half older than 65 years and nearly 25% over 75 years.5 The most relevant treatment modalities in elderly patients with gastroesophageal cancer remain a subject of debate. Although survival improvement has been observed during the past decade, prognosis remains significantly influenced by age.6 A recent population-based study, including patients with locoregional disease, showed a difference in treatment and survival according to age, comorbidity, race, and geographical region.7 In that analysis, elderly patients were less likely to undergo surgery and chemotherapy and, for the most part, this was attributed to the existence of comorbidity.7
In the current series from M.D. Anderson, it is apparent that older patients who were eligible for surgery sustained greater morbidity and had shorter overall survival than younger patients similarly treated. Although cause of death was not included, disease-free survival was less for the older patients. Thus, for the majority of patients with gastroesophageal cancer, surgery is associated with a somewhat higher risk of adverse outcomes. However, it is notable in this context that an aggressive program of chemotherapy and radiation was found to be well tolerated and effective in elderly patients with locally advanced esophageal cancer.8 Age-specific strategies based upon these observations warrant clinical investigation.
References
1. Holmes RS, Vaughan TL. Epidemiology and pathogenesis of esophageal cancer. Semin Radiat Oncol. 2007;17:2-9.
2. Morita M, et al. Esophagectomy in patients 80 years of age and older with carcinoma of the thoracic esophagus. J Gastroenterol. 2008;43:345-351.
3. Lagarde SM, et al. Prognostic factors in adenocarcinoma of the esophagus or gastroesophageal junction. J Clin Oncol. 2006;24:4347-4355.
4. Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol. 2001;2:533-543.
5. Remontet L, et al. Cancer incidence and mortality in France over the period 1978-2000. Rev Epidemiol Sante Publique. 2003;51:3-30.
6. Crane LM, et al. Oesophageal cancer in The Netherlands: Increasing incidence and mortality but improving survival. Eur J Cancer. 2007;43:1445-1451.
7. Steyerberg EW, et al. Referral patterns, treatment choices, and outcomes in locoregional esophageal cancer: a population-based analysis of elderly patients. J Clin Oncol. 2007;25:2389-2396.
8. Tougeron D, et al. Safety and outcome of definitive chemoradiotherapy in elderly patients with oesophageal cancer. Br J Cancer. 2008;99:1586-1592.
In a series of 600 consecutive patients with gastroesophageal cancer, older patient age was associated with more frequent surgical complications and shorter overall survival.Subscribe Now for Access
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