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- Population and method
Background: Advances have occurred in the management of digestive tract cancers, but it is not known how much they have benefited the elderly.
Aims: To determine trends in treatment, stage at diagnosis and prognosis of digestive tract cancers among patients aged ≥80 years in two well-defined French populations.
Design: Time trends were studied in three age classes and in 5 four-year time intervals. A multivariate relative survival analysis was performed to estimate the independent effect of both age and period on prognosis.
Results: Five-year relative survival rates were 1.9% for oesophageal cancer, 12% for stomach cancer, 41% for colon cancer and 37% for rectal cancer. The survival rates improved between the first and the fifth period for all cancer sites except for oesophageal cancer. This improvement remained significant after adjustment for age, sex, site and treatment. It was associated with an increase in the proportion of patients who underwent curative resection. Very few patients received adjuvant chemotherapy. The use of adjuvant radiotherapy for rectal and oesophageal cancers did not significantly increase over time.
Conclusions: Except for oesophageal cancers, substantial advances in the care of digestive tract cancers in the elderly have been achieved. Surgery should not be restricted on the basis of age alone. Further improvements can be made in particular to enhance adjuvant therapy whenever possible.
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- Population and method
Data concerning patterns of care and their trends over time in the elderly in a non-selected community-based series are rare. The aim was to provide non-biased and detailed statistics on the management of alimentary tract cancers in the elderly over a 20-year period. The multiplicity of information sources allows the assumption that nearly all newly diagnosed cases were recorded. There was no recruitment selection such as can be observed in specialized units. Information on treatment, stage at diagnosis and survival were almost exhaustive. Data were available for two French regions ensuring a study with a large number of cases. This study emphasizes the predominance of colon and rectal cancers among digestive tract cancers in the elderly. Stomach cancers ranked third and oesophageal cancers were rare. Due to the difference in life-expectancy between sexes (in 1996, it was respectively 74.1 years in men and 82.0 years in women), the proportion of digestive tract cancers increased in women compared with men with increasing age.
One of the main results of this study was the dramatic increase over time of survival rates for stomach, colon and rectal cancer. The study provides several explanations for this trend. There was a major increase in the proportion of patients resected for cure over the first three-study periods. Then it levelled out. Besides progress in perioperative management and resuscitation, this shows a change in the habits and opinions of surgeons and anaesthetists over the first 12 years of the study. The absence of recent improvement in the proportion of curative resection suggests that they consider they cannot be any more forceful. Another important trend was the decrease over time in the proportion of patients diagnosed with advanced stages. Several explanations can be put forward: earlier first consultation, more frequent and more rapid referral for investigations by general practitioners and a more forceful attitude of surgeons. However, there was no further improvements in the stage at diagnosis over the more recent study period. There was a substantial variation in the proportion of cases resected for cure varying with the location of the cancer: <1% for oesophageal cancers vs. 70% for colon cancers. Oesophageal surgery is a major surgery, associated with substantial post-operative morbidity and mortality. Many elderly patients are not suitable for such major surgery because of frequent pre-existing co-morbidities often related to alcohol and tobacco intoxication. This finding is consistent with the EUROCARE study, including several European countries and providing results for patients 75 and over.6 Another reason for the improvement of prognosis is the decrease of operative mortality over the study period, even though it remains higher than in younger patients. This is all the more noticeable as the proportion of patients who were offered surgery increased. Major progress has been made in the thorough evaluation and preoperative correction of associated medical conditions and by improvement in post-operative resuscitation. The proportion of patients resected for cure was lower for stomach cancers than for colon and rectal cancers and decreased with age. This can be explained at least partly by later presentation and thus by a poor performance status. An expectation of a poorer outcome or presence of co-morbidities are other possible explanations. The relative survival model, by disentangling the role of life-expectancy and coexisting pathologies from that of cancer itself, showed that age had a modest effect on prognosis. The prognostic effect of the period of diagnosis becomes borderline significant when adjusting for treatment in the multivariate relative survival model. Our data suggest that patients should not be denied resection because of age alone. Similar conclusions have been reached recently by hospital-based reports.7–12 Our data have also demonstrated significant differences in prognosis between sexes in the elderly. At the same age, women probably have less co-morbidity than men. The period of diagnosis was a significant factor associated to the curative resection independently of site, age and place of residence. Patients who were living in rural areas, as compared with urban areas, were less prone to be resected for cure. This is in line with a French study which underlined that individuals living in rural areas were less likely to seek medical advice than individuals living in urban areas.13
Chemotherapy has been demonstrated effective as adjuvant treatment in TNM stage III colon cancer, as palliative treatment for colorectal cancers and radiotherapy as preoperative treatment for rectal cancer.3, 10, 14 This study underlines that very few patients over the age of 80 received chemotherapy for stage III colon cancer after its effectiveness had been demonstrated. Similar results were reported by SEER-Medicare database: 2.4% of patients aged 80 and over received adjuvant chemotherapy for stage III colon cancer between 1992 and 1998.15 Recorded data in our study did not allow us to estimate the proportion of patients unsuitable for chemotherapy due to pre-existing co-morbidity or refusal of treatment. However, considering the increase in life-expectancy and the relatively low toxicity of chemotherapy in colon cancer, it can be concluded that a larger proportion of patients over 80 who were healthy enough to be operated could benefit from this treatment. The misconception that the elderly are more prone to side effects and that advanced age limits the potential benefit of treatment probably largely explains that chemotherapy has not reached its full development in the elderly. A review of five randomized clinical trials including elderly patients receiving systemic adjuvant and palliative treatment and comparing them to their younger counterparts showed that 5-FU-based treatment was equally effective in spite of more minor toxicity like mucite.16 However a US study reported a more intensive use of adjuvant chemotherapy over the 1991–1996 period: 34% of patients aged 80–84 years, 11% of those aged 85–89 years and 2% of those aged 90 and over.17 This data suggest that efforts can be made to provide this potentially curative treatment to more patients. A study has focused on the analysis of determinants of colon cancer treatment decisions and underlined that the major determinant of the patient's decision was their physician's advice.18 The importance that patients place on physician opinion makes it imperative that clinicians fully remind them of the potential benefit of chemotherapy. Similar comments can be made for palliative chemotherapy of advanced colorectal cancers. Radiotherapy is generally well tolerated in the elderly except the problem of iterative journeys between home and the radiotherapy centre. Radiochemotherapy has been demonstrated as more efficacious than radiotherapy alone. It should be used whenever possible. The few available data suggested that elderly colon or rectal cancer patients benefited from chemotherapy just as much as younger patients did, without significant additional side effects.19–21 The proportion of patients with rectal cancer receiving adjuvant radiotherapy slightly increased without reaching 20% during the last time period. As in chemotherapy, it was probably not made clear enough by recommendations that age alone should not exclude a patient from adjuvant or palliative treatment. Again co-morbidity and advanced age are more commonly cited reasons for not administering adjuvant therapies in patients with rectal cancer aged 75 and over than patient refusal.17, 22 Over the study period, radiotherapy alone remained the main treatment for oesophageal cancer, without significant trend over time. Radiochemotherapy, which is more effective than radiotherapy, could become an alternative in oesophageal cancer.
Experts have to spread targeted information to practitioners to ensure that maximum treatment benefit is obtained in elderly patients and further improvements could come from earlier stage at diagnosis or advances of more effective adjuvant and palliative treatments.