Comorbidity in older surgical cancer patients: Influence on patient care and outcome

doi:10.1016/j.ejca.2007.06.008

European Journal of Cancer

Volume 43, Issue 15, October 2007, Pages 2179-2193

https://doi.org/10.1016/j.ejca.2007.06.008 Get rights and content

Abstract

Evidence is scarce about the influence of comorbidity on outcome of surgery, whereas this information is highly relevant for estimating the surgical risk of cancer patients, and for optimising pre-, peri- and postoperative care. In this paper, the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I–III colorectal, stage I–II NSCLC or stage I–III breast cancer between 1995 and 2004 in the southern part of the Netherlands is summarised.

Almost all patients with stage I–III colon cancer or rectal cancer underwent surgery regardless of age or comorbidity. In contrast, the resection rate among elderly patients with stage I–II NSCLC was clearly lower than among younger patients and was significantly lower when COPD, cardiovascular diseases or diabetes were present. Among patients with stage I–III breast cancer, those aged 80 or older underwent less surgery, and the resection rate appeared to be lower when cardiovascular diseases or diabetes were present.

Among patients with resected colorectal cancer, postoperative morbidity and mortality were higher among those undergoing emergency surgery, and also among those with reduced pulmonary function, cardiovascular disease or neurological comorbidity. Among those with resected NSCLC, postoperative morbidity and mortality were related to reduced pulmonary function or cardiovascular disease. Since surgery for breast cancer is low risk, elective surgery, morbidity and mortality were not higher for elderly or those with comorbidity.

Among patients with colorectal or breast cancer, comorbidity in general, cardiovascular diseases, COPD, diabetes (only colon and breast cancer) and venous thromboembolism had a negative effect on overall survival, whereas the effect of comorbidity on survival of stage I–II NSCLC was less clear.

Elderly and those with comorbidity (especially cardiovascular diseases and COPD) among colorectal cancer and NSCLC patients had more postoperative morbidity and mortality. Prospective randomised studies are needed for refining selection criteria for surgery in elderly cancer patients and for anticipation and prevention of complications.

Introduction

Due to ageing of the population and rising incidence rates of most cancers with age, the mean age of patients diagnosed with cancer is increasing in western countries. This implies that patients increasingly suffer from one or more other serious (chronic) diseases, especially cardiovascular diseases, COPD, hypertension or diabetes.¹ Besides affecting life expectancy, comorbid conditions may complicate major surgery in cancer patients, especially when they are frail.2, 3, 4, 5, 6 Surgery is the only curative treatment option for patients with colorectal cancer, stage I–II non-small cell lung cancer (NSCLC) or breast cancer. Until now, there is lacking evidence about the influence of specific comorbid conditions on outcome of surgery as these elderly patients are often excluded from clinical trials. This information, however, is highly relevant for estimating the surgical risk of cancer patients, and for optimising pre-, peri- and postoperative care. Choice for surgery is clearly different among the different tumour groups. Generally speaking, surgery for colorectal cancer is often preferable because of bleeding or obstruction and the intention to perform a curative procedure (although in a non-curative setting alternative procedures are present). Surgery among lung cancer patients is high risk surgery, and radiotherapy is an alternative. Therefore, there is a strict selection of surgery among lung cancer patients. Surgery for breast cancer is low risk, but among older patients hormonal treatment is an alternative, which means that there is a more ‘elective’ selection.

In this paper, we summarise our findings with respect to the prognostic role of increasing age and comorbid conditions in patients diagnosed with stage I–III colorectal, stage I–II NSCLC or stage I–III breast cancer in the registration area of the population-based Eindhoven Cancer Registry, and discuss them against the background of the literature.

Section snippets

Patients and methods

The Eindhoven Cancer Registry records data on all patients newly diagnosed with cancer in the southern part of the Netherlands, an area with 2.3 million inhabitants and only with general hospitals. Since 1993, serious comorbidity with prognostic impact has been recorded for all patients. The Charlson comorbidity index is most widely used for recording comorbidity and was validated in various studies.⁷ We used a slightly modified version of this index for recording comorbidity. Comorbidity was

Surgery

Table 1 shows the general characteristics and resection rates of the patients.

Almost all patients with stage I–III colon cancer and stage I–III rectal cancer underwent surgery regardless of age or comorbidity (Fig. 1a and b). The proportion of patients with stage I–II NSCLC who underwent surgery was only 15% of those aged 80 or older versus 88% of age group 50–64 and 67% of those aged 65–79 (P < 0.01) (Fig. 1c). Among patients up to 80 years, the resection rate was significantly lower when COPD,

Surgery

When surgery is inevitable, like in patients with colorectal cancer, higher age or the prevalence of comorbidity did not significantly affect the resection rate. Surgery is the cornerstone for cure. Its goal is also to gain immediate relief of symptoms. Treatment options that do not focus on immediate relief of symptoms were, however, less applied in the elderly: several previous studies have shown that elderly patients with stage III colon carcinoma received less adjuvant chemotherapy and

Conclusions

Our study emphasises that comorbidity primarily has an impact on overall survival and less on postoperative complications, although high rates of postoperative complications remain. Comorbidity also leads to withholding surgical interventions if surgical therapy is commonly recognised as ‘high risk’ (e.g. stage I–II NSCLC) or if alternative non-surgical treatment is available (e.g. stage I–III breast cancer). Previous studies have shown that operative risk is especially high among colorectal

Take home messages

1.
Patients with comorbidity often have a poorer survival
2.
Anticipate postoperative complications in case of:
- (a)
  (Elderly) colorectal cancer patients with reduced pulmonary function, cardiovascular diseases or neurological comorbidity.
- (b)
  (Elderly) NSCLC patients with reduced pulmonary function or cardiovascular diseases.
3.
Prospective studies are needed for evaluating:
- (a)
  Screening tools or selection criteria for surgery in elderly or those with comorbidity.
- (b)
  Complications and recurrence rates in elderly cancer

Conflict of interest statement

None declared.

Acknowledgements

This work was carried out with grants from the Dutch Cancer Society (IKZ 2000-2260).

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Comorbidity in older surgical cancer patients: Influence on patient care and outcome

Abstract

Introduction

Section snippets

Patients and methods

Surgery

Surgery

Conclusions

Take home messages

Conflict of interest statement

Acknowledgements

Crit Rev Oncol Hematol

Lung Cancer

Ann Thorac Surg

J Chronic Dis

J Clin Epidemiol

Ann Oncol

Crit Rev Oncol Hematol

Crit Rev Oncol Hematol

Eur J Cancer

J Am Coll Surg

Crit Rev Oncol Hematol

Eur J Cancer

Thorac Surg Clin

Chest

Lung Cancer

Crit Rev Oncol Hematol

Lung Cancer

Crit Rev Oncol Hematol

J Am Coll Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Lung Cancer

Eur J Surg Oncol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Eur J Cancer

Int J Radiat Oncol Biol Phys

J Chronic Dis

Psychiatry Res

Eur J Cancer

Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older

JAMA

Comorbidity and functional status are independent in older cancer patients

J Clin Oncol

Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study

J Clin Oncol