Surgical mistreatment of older cancer patients


Year:

Session type:

Riccardo A. Audisio

Whiston Hospital, UK, and University of Liverpool, UK

Abstract

Surgical mistreatment of older cancer patients

There is redundant evidence that the older subset of our population is undergoing an unprecedented expansion. This is not only taking place in western countries, but also in several areas with an emerging economy.

There is also evidence that cancers, with the exception of cervical cancer, prevails among senior citizens.

Surgery is the first choice treatment for solid malignancies, as clearly stated by guidelines and recommendations. Unfortunately hard data accumulated over the last decade (1) confirm that surgery is not being delivered as per guidelines to the elderly cancer patient. This includes poor staging as well as substandard treatment, and results into a reduced relative (cancer-related) survival (2).

The excess of operative mortality in colorectal elderly cancer patients treated in the emergency setting could be reduced by temporarily palliating the obstruction with a stent. Expandable stenting devices have been made available for over a decade and it is surprising how they have not become sufficiently popular in the UK, as well as abroad, despite the efforts of colorectal surgeons in this country (3).

Breast cancer in older women is also badly tackled among this age group. Although surgical excision has been accepted as the standard of care until the 80’s, some reports suggesting the efficacy of hormonal treatment shifted the management of the majority of patients aged 80 and above from surgery to hormonal treatment; this is surprising as the mortality rate for breast surgery is almost neglectable (4). Regrettably, this is not only a national flow, but similar evidence has been recorded almost everywhere (5).

The problem rests on our poor knowledge in assessing the fitness for surgery (6). Time has come we put a significant effort in better understanding the surgical risk (7). Tools such have been developed by geriatricians and are now available to surgical wards after appropriate validation (8).

It is imperative to tailor cancer treatment on every single patient and the decision should be made on hard evidence, rather than on an obsolete rule of thumb. Oncogeriatric patients deserve much better management.

References

1. Turner NJ, Haward RA, Mulley GP, Selby PJ. Cancer in old age--is it inadequately investigated and treated? BMJ. 1999 Jul 31;319(7205):309-12.

2. Tekkis PP, Poloniecki JD, Thompson MR, Stamatakis JD. Operative mortality in colorectal cancer: prospective national study. BMJ. 2003 Nov 22;327(7425):1196-201.

3. http://demo.e-dendrite.com/csp/icrstent/frontpages/icsrFront.csp

4. Hind D, Wyld L, Beverley CB, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004272.

5. Owusu C, Lash TL, Silliman RA. Effect of undertreatment on the disparity in age-related breast cancer-specific survival among older women. Breast Cancer Res Treat. 2007 Apr;102(2):227-36.

6. Audisio RA, Ramesh H, Longo WE, Zbar AP, Pope D. Preoperative assessment of surgical risk in oncogeriatric patients. Oncologist. 2005 Apr;10(4):262-8.

7. Pope D, Ramesh H, Gennari R, Corsini G, Maffezzini M, Hoekstra HJ, Mobarak D, Sunouchi K, Stotter A, West C, Audisio RA. Pre-operative assessment of cancer in the elderly (PACE): a comprehensive assessment of underlying characteristics of elderly cancer patients prior to elective surgery. Surg Oncol. 2006 Dec;15(4):189-97.

8. PACE participants, Audisio RA, Pope D, Ramesh HS, Gennari R, van Leeuwen BL, West C, Corsini G, Maffezzini M, Hoekstra HJ, Mobarak D, Bozzetti F, Colledan M, Wildiers H, Stotter A, Capewell A, Marshall E. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol. 2008 Feb;65(2):156-63