Management of Colorectal Cancer in Older Adults

Surgery

Early-Stage Disease

When possible, surgical resection of colorectal tumors is the primary treatment in both the curative setting and to avoid complications, such as obstruction or perforation.²⁷ Multiple studies have shown that fit elderly patients benefit from curative surgery similarly to their younger counterparts.^27–29 With the growing population of persons aged 65 years or older, surgeons are becoming more comfortable with operating on the elderly.⁴ However, a large systematic review of 28 independent studies with a total of 34,194 patients showed that older patients were less likely to undergo curative surgery.³⁰ Eligibility for surgery should not be determined by age alone, but rather should be based on a full assessment of the patient’s health, including comorbidities, functional status, nutrition, cognition, social support, and psychological status. The impact of age on short-term outcomes after colorectal surgery in terms of 30-day postoperative morbidity and mortality rates was explored in a study that divided patients into 2 groups: those aged ≥ 80 years (mean age 85) and those aged < 80 years (mean age 55.3).³¹ There were no statistical differences in 30-day postoperative morbidity and mortality rates between the 2 groups, and preexisting comorbidities and urgent nature of surgery were important predictors of colorectal surgery outcomes in the older adults, results that have been seen in several other studies.^28,30 When possible, laparoscopic surgery is preferred as it is associated with less intraoperative blood loss, less postoperative pain, reduced postoperative ileus, a shorter hospital stay, and fewer cardiovascular and pulmonary complications.³² The Preoperative Assessment of Cancer in the Elderly (PACE), which combines surgical risk assessment tools with CGA tools, can assist surgeons in determining candidacy for surgery and help decrease unequal access to surgery in the geriatric population.³³

Metastasectomy

A large international multicenter cohort study explored the outcomes of patients aged ≥ 70 years who underwent liver resection of colorectal metastases. The study investigatorsfound that neoadjuvant chemotherapy was used less frequently and less extensive surgery was performed in elderly patients than in younger patients.³⁴ Sixty-day postoperative mortality was slightly higher (3.8% versus 1.6%, P < 0.001) and 3-year OS was slightly lower (57.1% versus 60.2%, P < 0.001) in the elderly group as compared to their younger counterparts, but overall the outcomes after liver surgery were similar. Therefore, the management of liver metastases in oligometastatic disease in elderly patients fit for surgery should be the same as that offered to younger patients. Since outcomes are comparable, older patients should be offered neoadjuvant chemotherapy, as several studies have shown similar response rates and OS in younger and older patients.^35,36

Rectal Cancer

The standard of care for locally advanced rectal cancer is combined modality treatment with radiation and chemotherapy followed by total mesorectal excision. However, given conflicting data regarding the ability of elderly patients to tolerate neoadjuvant 5-FU-based chemotherapy and radiation, elderly patients are treated with trimodality therapy less often than their younger counterparts.^37,38 A systematic review of 22 randomized trials involving 8507 patients with rectal cancer showed that adjuvant radiation therapy could reduce the risk of local recurrence and death from rectal cancer in patients of all ages.³⁹ However, the risk of noncancer-related death was increased in the older population. The Stockholm II trial showed similar benefits of preoperative radiation overall, but this benefit did not extend to patients older than 68 years because of an increased risk of morbidity and mortality.⁴⁰ In older patients, mortality from noncancer causes within the first 6 months after surgery was higher in the group that received perioperative radiation than in the group that did not receive radiation. Elderly patients (age > 68 years) accounted for most of the mortality, which was predominantly due to cardiovascular disease.