Resection for esophageal cancer in the elderly

Abstract

Although studies differ in their definition of the older patient, increasing age, when considered as a continuum, is associated with greater operative mortality. Complication rates also seem to be significantly higher with advancing age, possibly because of limited physiologic reserve. As the understanding of risk factors for perioperative morbidity and mortality following esophagectomy has improved, investigators have sought to develop models for risk stratification in which patient age is a significant but not the sole determinant of prospective assessment of risk for complication or mortality. Such prognostic indicators, if validated among independent patient cohorts, can serve as useful adjuncts in decision making with appropriate clinical judgment. In addition, reported patient survival differs dramatically between rates reported by single centers and rates observed in population-based studies, with operative mortality rates typically lower in single-center reports. Although such reports usually are issued from groups with higher operative volume that might be a surrogate for surgical experience, it also is possible that the association between operation volume and improved outcomes reflects optimization of institution-specific infrastructure and/or clinical care pathways. As these processes of care evolve, they should be tailored with attention to differences in the care of older patients who have esophageal cancer. Whether widespread application of such processes of care then can lead to less perioperative mortality and fewer complications and to improved long-term survival remains untested.

Figure 1

Distribution of new cases of (bar) and deaths due to (line) esophageal cancer among cohorts of age, 2001–2005, Surveillance, Epidemiology and End Results. Data from [2].

Figure 2

A, Operative mortality following esophagectomy, 1994–2003 Nationwide Inpatient Sample. B, Overall five-year survival following esophagectomy for cancer, 1992–2001 SEER-Medicare linked database. Data from J Am Coll Surg, vol. 205, Finlayson E, Fan Z and Birkmeyer JD, “Outcomes in octogenarians undergoing high-risk cancer operation: a national study,” pp. 729–734, © 2007, with permission from Elsevier.

Figure 3

Kaplan-Meier overall survival following esophagectomy for esophageal cancer, stratified by age, University of Michigan, 1993–2008. .