New research shows that outcomes of high-risk cancer operations in 80-year-olds are considerably worse than reported in case studies and published survival statistics. It may lead to unrealistic expectations about the safety of these operations in the elderly. With this limited information, elderly patients and their physicians may have difficulty accurately assessing the risks and benefits of major cancer operations.
An increasing number of the very elderly are undergoing major cancer operations as the population ages. Between 1994 and 2003, total surgical discharges after lung, esophageal and pancreatic resection in patients aged 80 years and older increased by 76 percent, and this new number is expected to increase by more than 50 percent by 2020. Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case studies from tertiary care centers, which perform high volumes of these procedures and thus have superior outcomes. For lung, esophageal and pancreatic resection, single-center studies report operative mortality rates between 3 and 4 percent for the very elderly.
"Our study showed that there is a need to improve patient outcomes in the elderly nationwide," said lead investigator of the study Emily Finlayson, MD, MS, assistant professor of surgery, University of Michigan. "Furthermore, it provides a wake up call that the realistic risks and long-term benefits of major cancer operations differ for older patients when compared to their younger counterparts. This difference is essential to consider when surgeons and their older patients are making decisions about whether or not to have this type of surgery, particularly if the patient has other existing medical issues as this further affects the risk-benefit equation."
Researchers conducted a retrospective cohort study of patients undergoing major resections for lung, esophageal and pancreatic cancer using short-term data from the Nationwide Inpatient Sample (NIS) database to assess operative mortality and discharge in octogenarians relative to younger patients (aged 65 to 69 years). Long-term data from the Surveillance and End Results Medicare database was then used to measure late survival in the elderly.
"We believe that our population-based study yields more realistic results because it is representative of patient data from 1,000 hospitals across the country, not just data from the top hospitals," added Dr. Finlayson.
According to the NIS database, between 1994 and 2003 an estimated 200,000 patients aged 65 years and older underwent resection for lung, esophageal or pancreatic cancer. For all three procedures, death during the surgical procedure among octogenarians was substantially higher than that of younger patients for all three cancers (esophagectomy, 19.9 percent versus 8.8 percent, p<0.0001; pancreatectomy, 15.5 percent versus 6.7 percent, p<0.0001; lung resection, 6.9 percent versus 3.7 percent, p<0.0001). Older age was strongly associated with decreased likelihood of being discharged to home after the operation. A large proportion of octogenarians were transferred to extended-care facilities after their operations, ranging from 24 percent after lung resection to 44 percent after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11 percent after pancreatectomy, 18 percent after esophagectomy and 31 percent after lung-cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbidities.