Page 13 - Risk quantification and modification in older patients with colorectal cancer

Colorectal cancer (CRC) is the second most common cancer worldwide. In the Netherlands, the number of newly diagnosed patients is around 15,000 per year, with more than 50% of these patients being 70 years and older.1 In the decades to come, the number of older patients with colorectal cancer is expected to increase due to unfavourable lifestyle changes, increased life-expectancy and early detection programs.2 The mainstay of curative treatment for stage I-III involves surgical resection.3 But with advancing age, there is an increased risk for adverse outcomes of surgery such as postoperative complications, readmission or even death.4-6 In addition, surgery may have a prolonged impact on older patients,7 including decreased physical functioning8 and quality of life.9-11 In individual patients, these adverse outcomes may outweigh the possible benefits of surgery, such as symptom relief or cancer survival.
Selecting the appropriate cancer treatment for older patients is challenging. Scientific evidence is lacking because older patients, especially frail older patients, are underrepresented in clinical trials.12,13 Hence, in clinical practice, there is often uncertainty what the best cancer treatment is for an individual patient. In CRC care, this is demonstrated by the considerable treatment variation with respect to radiotherapy and surgery for rectal cancer patients and adjuvant chemotherapy for patients with stage III colon cancer.14,15
Traditionally, treatment decisions have depended on age, ASA (American Society of Anesthesiologists) score or the physical performance scale (PS). However, these criteria do not capture the heterogeneity of health and physical performance of older patients.16 Fortunately, there is a growing number of studies that have investigated risk factors and methods that can direct cancer treatment decisions in older patients. In addition, pre- and perioperative interventions that are aimed to improve outcomes of older patients have become available or are already implemented into standard CRC care.
Quantifying the risk for adverse outcomes
In older patients, undernutrition,17 cognitive impairment, polypharmacy,18-20 reduced mobility and impaired physical performance21,22 have been identified as important risk factors for increased risk of postoperative complications,
Introduction and thesis outline
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