Pancreatic Cancer Resection in Elderly Patients
Pancreatic Cancer Resection in Elderly Patients
ABSTRACT & COMMENTARY
Synopsis: In this retrospective report, the influence of age on pancreatic cancer resection was examined. Although a smaller percentage of older patients were "resectable," for those that went to surgery, perioperative morbidity and mortality were comparable to younger patients. Overall survival was slightly less for the older, resected patients, but it was apparent that factors other than age were responsible for this difference. Dicarlo and colleagues contend that patient age is not a contraindication to modern surgical approaches for pancreatic cancer.
Source: Dicarlo V, et al. Br J Surgery 1998;85: 607-612.
Pancreatic cancer incidence increases with advancing age1 and, despite the development of new radiation therapy and chemotherapy approaches, surgery remains by far the best chance for cure. Advances in surgical techniques have reduced perioperative morbidity and mortality,2-4 and what was once a procedure only suggested for otherwise healthy, young patients, is now offered to many patients, including the elderly. In this report, the clinical approach for 398 consecutive patients with pancreatic cancer treated at San Raffaele Hospital in Milan between 1990 and 1995 was reviewed. Of these, 128 had pancreatic resection. Patients over the age of 70 (n = 33) were compared to those under this age (n = 85). The ability to resect the tumor was equivalent in both groups and operative morbidity and mortality were comparable. Older patients had more relaparotomies and more hemorrhagic complications. Nutritional recovery after resection (body weight gain after surgery and increase in serum albumin) was similar for both age groups. Univariate analysis revealed a trend toward long-term survival advantage for the younger patients (P = 0.09) but multivariate analysis demonstrated that tumor diameter, histological grade, and clinical stage were independent prognostic factors, whereas age was not.
COMMENTARY
This is a non-randomized, clinical series that makes a point, albeit difficult to substantiate with the data presented. There is no doubt that clinicians are and will continue to be faced with the problem of older patients with pancreatic cancer. It is also clear that older patients subjected to cancer surgery fare better than expected if perioperative morbidity was predicted based solely upon patient age. Yet, comorbidities occur more frequently in the elderly and we still do not have firm data on operative success for the older patient with several other medical problems. Most surgical oncologists agree that the "fit" elderly are usually good surgical candidates, but the presence of various comorbidities dampens the enthusiasm for aggressive surgical procedures, just as it would in younger patients with the same conditions.
This report was instructive in this regard. Among the 270 patients older than 60 years, 1% in the 60-69 year age group, 8% in the 70-79 year age group, and 13% in the 80 years and older age group were excluded from surgery because of "poor general condition." Other factors contributed to the resectability (such as the presence of distant metastases or advanced local infiltration), such that resection was attempted in 29%, 35%, and 9% in these three age groups, respectively.
Median survival was slightly worse for those older than 70 years (14 months vs 16 months; P = 0.09), but this was attributed to the larger tumors, higher stage, and poorer histological grade in this group. In fact, in multivariate analysis, age itself did not predict survival for resected patients. Another factor that may have influenced survival was the less aggressive surgical approach in the older group and the lower frequency of adjuvant therapy. For example, an average of 18 lymph nodes were removed at the time of surgery for the younger patients and 13 for the older patients. Despite the larger diameters of tumors removed from the older patients (3.8 cm vs 3.0 cm for the younger patient), less adjuvant therapy (intra-operative radiation therapy, chemotherapy, and external beam radiation therapy) was prescribed for the older patients (55% for the older group, 78% for the younger group).
Thus, in this retrospective, non-randomized series, uncontrolled variables preclude a confident comparison of the efficacy modern surgical approaches among the various age groups. Nonetheless, this impressive series lends support to an aggressive surgical approach for selected older patients in that it demonstrated that perioperative morbidity and mortality were no different for the older group. It remains to be seen, however, if this surgical approach can be adapted to the elderly patient with multiple comorbidities.
References
1. Boyle P, et al. Int J Pancreatology 1989;5:327.
2. Grace PA, et al. Am J Surgery 1986;151:141.
3. Trede M, et al. Ann Surgery 1990;211:447.
4. Cameron JL, et al. Ann Surgery 1993;217:430.
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